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EASL 2015: Hepatitis C Treatment May Be Highly Cost-effective for Prisoners in England

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Reducing the duration of direct-acting antiviral therapy for hepatitis C will make treatment for prisoners in England highly cost-effective, and could provide an important opportunity for providing access to hepatitis C treatment for people who inject drugs, Natasha Martin from the University of California San Diego reported at the European Association for the Study of the Liver (EASL) 50th International Liver Congress last month in Vienna.

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People who inject drugs may be more likely to be exposed to hepatitis C virus (HCV) during a spell in prison. This is due both to the high prevalence of HCV among fellow prisoners and the potential for sharing non-sterile injecting and drug preparation equipment, especially in prison systems where harm reduction measures are not made available.

Reducing the burden of hepatitis C among prisoners offers a potentially significant opportunity for reducing the overall burden of hepatitis C among people who inject drugs and for reducing onward transmission of HCV -- both amongst prisoners and in the community. Prison may provide an opportunity to deliver high-quality health care and supervised treatment for individuals who might otherwise lack a fixed address and have very limited engagement with medical services.

A proof-of-concept study of hepatitis C treatment as a means of reducing onward transmission -- treatment as prevention -- recently began in Australia. But in many countries, including England, hepatitis C testing and treatment rates remain very low among prisoners and among people who inject drugs.

Opt-out testing for HCV was introduced in prisons in England and Wales in 2014, but the long duration of interferon-based therapy means that prisoners are often released before treatment can be completed, making the scale up of interferon-based treatment in prisons impractical. Shorter treatment courses of 8 to 12 weeks using direct-acting antivirals would be more effective and more likely to be completed before release, but the cost-effectiveness of interferon-free treatment in prison populations is unclear.

Using a model developed to project the dynamics of HCV transmission among prison populations in England and Wales, Martin and epidemiologists at the University of Bristol calculated the cost-effectiveness of an 8- or 12-week treatment course which achieves a 95% cure rate. They also considered the effects of variations in the rate of HCV testing, referral to treatment, and treatment initiation.

The model assumed that it would be possible to test 1.5% of the prison population each week, of whom 15% would be diagnosed with hepatitis C. The assumed prevalence is based on recent sampling, but antibody testing among prisoners in England and Wales between 2005 and 2008 found a mean prevalence of 25% among those referred for testing. No anonymized seroprevalence survey has been carried out since 1997.

In the model just over half (56%) of those diagnosed would be referred for hepatitis C treatment, and of these, 25% of former drug injectors and 2.5% of current injectors would start treatment within 2 months of diagnosis. The estimate takes into account treatment completion rates too: people currently injecting drugs will spend an average of 4 months in prison, while former drug users will spend an average of 8 months in prison.

The model assumed a regimen cost of £3200 (about US$5000) per week for direct-acting antivirals -- the currently anticipated cost for sofosbuvir/ledipasvir (Harvoni) in England and Wales -- and a cure rate of 95%.

The model showed that doubling prison HCV testing rates and following the assumptions of the model regarding treatment uptake would result in an incremental cost-effectiveness ratio of £25,766 (about $40,300) per quality-adjusted life-year gained for direct-acting antiviral treatment compared to interferon-based treatment. This level is considered cost-effective in England and Wales.

Doubling the rate of treatment would reduce the cost-effectiveness ratio to £21,678 (about $33,900) per QALY, while reducing the duration of treatment to 8 weeks would cause the cost-effectiveness ratio to fall to £12,323 (about $19,300), making treatment highly cost-effective. If 25% of people who inject drugs were treated as a result of referral, the cost-effectiveness would fall to around £5,000 (around $7,800). However, the affordability of scaling up treatment for all who need it is unclear, said Martin.

5/18/15

Reference

NK Martin, P Vickerman, IF Brew, et al. Is increased HCV case-finding combined with 8 or 12 week interferon-free direct-acting antiviral treatment cost-effective in UK prisons? A cost utility analysis including treatment as prevention benefits. 2015 International Liver Congress: 50th Annual Meeting of the European Association for the Study of the Liver (EASL). Vienna, April 22-26, 2015. Abstract O124.