Cost and cost-effectiveness of a real-world HCV treatment program among HIV-infected individuals in Myanmar

Abstract

IntroductionOver half of those hepatitis C virus (HCV)/HIV coinfected live in low-income and middle-income countries, and many remain undiagnosed or untreated. In 2016, Médecins Sans Frontières (MSF) established a direct-acting antiviral (DAA) treatment programme for people HCV/HIV coinfected in Myanmar. The purpose of our study was to evaluate the real-world cost and cost-effectiveness of this programme, and potential cost-effectiveness if implemented by the Ministry of Health (MoH).MethodsCosts (patient-level microcosting) and treatment outcomes were collected from the MSF prospective cohort study in Dawei, Myanmar. A Markov model was used to assess cost-effectiveness of the programme compared with no HCV treatment from a health provider perspective. Estimated lifetime and healthcare costs (in 2017 US$) and health outcomes (in disability-adjusted life-years (DALYs)) were simulated to calculate the incremental cost-effectiveness ratio (ICER), compared with a willingness-to-pay threshold of per capita Gross Domestic Product in Myanmar ($1250). We evaluated cost-effectiveness with updated quality-assured generic DAA prices and potential cost-effectiveness of a proposed simplified treatment protocol with updated DAA prices if implemented by the MoH.ResultsFrom November 2016 to October 2017, 122 with HIV/HCV-coinfected patients were treated with DAAs (46% with cirrhosis), 96% (n=117) achieved sustained virological response. Mean treatment costs were $1229 (without cirrhosis) and $1971 (with cirrhosis), with DAA drugs being the largest contributor to cost. Compared with no treatment, the program was cost-effective (ICER $634/DALY averted); more so with updated prices for quality-assured generic DAAs (ICER $488/DALY averted). A simplified treatment protocol delivered by the MoH could be cost-effective if associated with similar outcomes (ICER $316/DALY averted).ConclusionsUsing MSF programme data, the DAA treatment programme for HCV among HIV-coinfected individuals is cost-effective in Myanmar, and even more so with updated DAA prices. A simplified treatment protocol could enhance cost-effectiveness if further rollout demonstrates it is not associated with worse treatment outcomes.

Health and economic benefits of achieving hepatitis C virus elimination in Pakistan: A modelling study and economic analysis

“…There is increasing evidence that scaling up HCV treatment is highly cost-effective and potentially cost-saving in a number of settings. Subnational studies in various LMICs have shown DAA treatment of HCV-diagnosed patients to be cost-effective in Myanmar [ 47 ] and cost-saving in India, Thailand, and South Africa, but they did not include screening costs [ 48 ]. Other subnational studies in Egypt [ 49 ], Cambodia [ 6 ], and Pakistan [ 21 ] have shown that screening and DAA treatment can be cost-effective or possibly cost-saving when compared to no screening and treatment.…”

Cost‐effectiveness of a decentralized, community‐based “one‐stop‐shop” hepatitis C testing and treatment program in Yangon, Myanmar

“…[28][29][30] Within Myanmar, MSF proposed a simplified model of HCV care to the Myanmar Ministry of Health, which incorporated fewer patient visits, task-shifting from doctors to nurses and using local staff, and was estimated to be highly costeffective (ICER <USD400/DALY averted compared with no treatment in HCV/HIV coinfected patients). 31 We used WHO-prequalified generic DAAs ordered and imported via pooled procurement, so our DAA price was lower than private clinics in Myanmar (SOF/DCV price USD399 (2018) to USD330 (2019) for 12-week treatment versus USD86.76 for 12-week treatment in CT2). Therefore, we conducted sensitivity analyses for 12-week treatment prices of USD300, 20 USD150 based on the DAA prices in Myanmar, and USD28 (from a neighboring country [Pakistan]), 10 finding that the CT2 model of care had a 90% probability of being costeffective if measured against a willingness-to-pay thresholds of 60%, 30%, or 12% per capita GDP respectively (see Appendix).…”

“…Our findings are consistent with other studies regarding the cost‐effectiveness of HCV testing and treatment in LMICs that have shown treating HCV with generic DAAs is cost‐effective 28–30 . Within Myanmar, MSF proposed a simplified model of HCV care to the Myanmar Ministry of Health, which incorporated fewer patient visits, task‐shifting from doctors to nurses and using local staff, and was estimated to be highly cost‐effective (ICER <USD400/DALY averted compared with no treatment in HCV/HIV coinfected patients) 31 …”

Primer reporte en Perú sobre terapia con antivirales de acción directa para hepatitis C crónica en pacientes VIH-positivos

“…La terapia para hepatitis C crónica en pacientes VIH-positivos es costo-efectiva (19) , por lo que todos los pacientes deberían ser tratados oportunamente y en serie, inde-pendientemente del estadio de fibrosis hepática. Para ello, se requiere un esfuerzo y organización real de los programas de VIH; pero aun eso no será suficiente.…”