Cost-effectiveness of Universal Hepatitis C Virus Screening of Pregnant Women in the United States

Abstract

General rightsThis document is made available in accordance with publisher policies. Please cite only the published version using the reference above. Full terms of use are available: http://www.bristol.ac.uk/pure/userguides/explore-bristol-research/ebr-terms/ ABSTRACT Background: Hepatitis C Virus (HCV) chronic prevalence among pregnant women in the United States (U.S.) U.S. doubled nationally from 2009-2014 (~0.7%), yet many remain undiagnosed. Screening pregnant women is not recommended by the Society of Maternal-Fetal Medicine or the Centers for Disease Control and Prevention, despite new AASLD/IDSA guidelines recommending screening this group. We assessed the cost-effectiveness of HCV screening for pregnant women in the U.S. Methods:An HCV natural history Markov model was used to evaluate the cost-effectiveness of universal HCV screening of pregnant women followed by treatment after pregnancy compared to background riskbased screening from a health care payer perspective. We assumed 0.73% HCV chronic prevalence among pregnant women based on national data. We assume no Medicaid reimbursement restrictions by fibrosis stage at baseline, but explore differing restrictions in sensitivity analyses. We assessed cost (in USD$) and health outcomes (in quality-adjusted life years, QALYs) over a lifetime horizon, using new HCV drug costs of $25,000/treatment. We assess mean incremental cost-effectiveness ratios (ICERs) under a willingness to pay threshold of $50,000/QALY gained. We additionally evaluate potential population impact.Results: Universal antenatal screening was cost-effective in all treatment eligibility scenarios (mean ICER <$3,000/QALY gained). Screening remained cost-effective at 0.07% prevalence, the lowest estimated prevalence state in the U.S. (Hawaii). Screening the ~5.04 million pregnant women in 2018 could result in detection and treatment of 33,000 women based on current fibrosis restrictions. Conclusions:Universal screening for HCV among pregnant women in the U.S. is cost effective and should be recommended nationally.

CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020

“…Analyses focusing on pregnant women have yielded similar results. One analysis calculated an ICER of $2,826 for universal screening of pregnant women under the health care perspective, compared with risk-based screening at an HCV RNA positivity prevalence of 0.73%; sensitivity analyses generated an ICER of $50,000 per QALY gained or less until the prevalence of chronic hepatitis C infection dropped to 0.03%-0.04% (92).…”

“…According to modeling results using NHANES data, no state has a hepatitis C prevalence in adults below 0.1% (9). Similarly, for universal testing in pregnant women, ICER would be approximately $50,000 per QALY gained or less at an HCV RNA positivity prevalence of 0.05%; at a prevalence of 0.1%, ICER would be approximately $15,000 per QALY gained (92). ICERs might be higher for testing in subsequent pregnancies when testing during the index pregnancy identifies women with hepatitis C who receive treatment following pregnancy, resulting in a decrease in hepatitis C prevalence among women with more than one pregnancy.…”

Review article: direct‐acting antivirals for the treatment of HCV during pregnancy and lactation ‐ implications for maternal dosing, foetal exposure, and safety for mother and child

“…It is, however, not being implemented widely thus far as other guidelines, such as from the Centers for Disease Control and Prevention and the Society for Maternal‐Foetal Medicine, have not yet adopted the recommendation. It is estimated that such a screening strategy, followed by treatment after pregnancy, would be cost‐effective for maternal treatment and would identify around 300 newborns with vertical HCV in the USA annually . However, pregnant women may experience psychological stress as treatment start has to be postponed to the postpartum period.…”

HCV in Women and Pregnancy

“…(57,58) Conversely, universal screening for HCV has been shown to be cost-effective in all treatment eligibility scenarios and US prevalence rates, estimating that universal screening of pregnant women would result in the identification of 33,000 HCV-positive women in 2018 alone. (59) Given the increasing burden of disease in this population, there is increasing interest in treatment in pregnancy, with the simultaneous goals of interrupting vertical transmission and achieving cure with a majority of HCV-positive women interested in treatment during pregnancy, to prevent mother-to-child transmission. (60) Prospective data on DAA therapy in pregnancy is limited to a single study (n = 7) evaluating a 12-week course of sofosbuvir/ledipasvir in genotype 1 infection.…”