Cost-effectiveness of expanded antiviral treatment for chronic hepatitis B virus infection in China: an economic evaluation

Abstract

Background: China, which has the largest chronic hepatitis B virus (HBV) burden, may expand antiviral therapy to attain the World Health Organization (WHO)-2030 goal of 65% reduction in mortality. We evaluated health outcomes and cost-effectiveness of chronic HBV infection treatments based on alanine transaminase (ALT) antiviral treatment initiation thresholds and coverage in China to identify an optimal strategy.

Methods: A decision-tree Markov state-transition model evaluated the cost-effectiveness of expanded antiviral treatment for chronic HBV infection by simulating 136 scenarios by ALT treatment initiation thresholds (40 U/L, 35 U/L for males and 25 U/L for females, 30 U/L for males and 19 U/L for females, and treating HBsAg+ individuals regardless of ALT values), population age groups (18-80, 30-80, and 40-80 years), implementation durations (2023, 2028, and 2033) under and treatment coverages (20%, 40%, 60%, and 80%). Deterministic and probabilistic sensitivity analyses explored model uncertainty.

Findings: Besides the status quo, we finally simulated 135 treatment-expanding scenarios based on the cross combination of different thresholds of ALT, treatment coverages, population's age groups and implementation time. For the status quo, a cumulative incidence of 16,038-42,691 HBV-related complications and 3116-18,428 related deaths will happened between 2030 and 2050. When the treatment threshold is expanded to 'ALT > 35 in males & ALT > 25 in females' immediately without expanding treatment coverage, it will save 2554 HBV-related complications and 348 related deaths compared to the status quo among the whole cohort by 2030, and US$ 156 million more will be costed for gaining 2962 more QALYs. If we just expand the ALT threshold to ALT > 30 in males & ALT > 19 in females, 3247 HBV-related complications and 470 related deaths will be prevented by 2030 under the current treatment coverage of 20%, which will cost US$ 242 million, US$ 583 million or US$ 606 million more by the year of 2030, 2040 or 2050, respectively. Treatment expanded to HBsAg+ will save the largest number of HBV-related complications and death. This expanding strategy also results in large complications or death reduction when it is limited to patients older than 30 years or 40 years. Under this strategy, four scenarios (Treating HBsAg+ with coverage of 60% or 80% for patients older than 18 years or 30 years) showed the effectiveness in reaching the target before the year 2030. Among all the strategies, treatment expanded to HBsAg+ would cost the most while providing the highest total QALYs compared to other strategies with similar implementation scenarios. ALT thresholds of 30 U/L and 19 U/L for males and females, respectively, with 80% coverage for 18-80 years, can attain the goal by 2043.

Interpretation: Treating HBsAg+ individuals with 80% coverage for 18-80 years is optimal; earlier implementation of expanded antiviral treatment with a modified ALT threshold could decrease HBV-related complications and deaths to support the global target of 65% reduction in viral hepatitis B deaths.

Funding: This study was funded by Global Center for Infectious Disease and Policy Research (BMU2022XY030); Global Health and Infectious Diseases Group (BMU2022XY030); The Chinese Foundations for Hepatitis Control and Prevention (2021ZC032); National Science and Technology Project on Development Assistance for Technology, Developing China-ASEAN Public Health Research and Development Collaborating Center (KY202101004); in part by National Key R&D Program of China (2022YFC2505100).

Keywords: Alanine transaminase; Chronic HBV infection; Cost-effectiveness; Treatment.

Fig. 1

Effect of strategies to reduce mortality attributable to CHB implemented from 2023 in China. a, c, e, g and i, reduced mortality by 2030, 2035, 2040, 2045, and 2050 respectively; b, d, f, h and j, the annual incidence of each strategy that could reach 65% mortality-reduction target by 2030, 2035, 3040, 2045, and 2050, respectively;k, the year in which each strategy achieved the goal of reduced mortality by 65%. Abbreviation: THBs, Treating HBsAg+; 30/19, ALT > 30/19; 35/25, ALT > 35/25; 40, ALT > 40; 18–80, 18–80 years; 30–80, 30–80 years; 40–80, 40–80 years.

Fig. 2

Cumulative incidence of HBV-related complications for 18–80 years implemented from 2023. a, Treating HBsAg+; b, ALT > 30/19; c, ALT > 35/25; d, ALT > 40. Abbreviation: CC, compensated cirrhosis; DC, decompensated cirrhosis; HCC, hepatocellular carcinoma; RC, reduced complications.

Fig. 3

Cost-effectiveness plane demonstrating the cost-effectiveness for all treatment strategies of the HBV treatment programs by 2050 implemented from 2023, 2028, and 2033. Strategies on the cost-effectiveness frontier dominate strategies above the frontier. Abbreviation: THBs, Treating HBsAg+; 30/19, ALT > 30/19; 35/25, ALT > 35/25; 40, ALT > 40; 18–80, 18–80 years; 30–80, 30–80 years; 40–80, 40–80 years.

Fig. 4

Cost-effectiveness acceptability curves for HBV treatment strategies of the HBV treatment programs by 2050 implemented from 2023, 2028, and 2033. Strategies on the cost-effectiveness frontier dominate strategies above the frontier.