Improved Health Outcomes from Hepatitis C Treatment Scale-Up in Spain’s Prisons: A Cost-Effectiveness Study

Abstract

Hepatitis C virus (HCV) is 15 times more prevalent among persons in Spain’s prisons than in the community. Recently, Spain initiated a pilot program, JAILFREE-C, to treat HCV in prisons using direct-acting antivirals (DAAs). Our aim was to identify a cost-effective strategy to scale-up HCV treatment in all prisons. Using a validated agent-based model, we simulated the HCV landscape in Spain’s prisons considering disease transmission, screening, treatment, and prison-community dynamics. Costs and disease outcomes under status quo were compared with strategies to scale-up treatment in prisons considering prioritization (HCV fibrosis stage vs. HCV prevalence of prisons), treatment capacity (2,000/year vs. unlimited) and treatment initiation based on sentence lengths (>6 months vs. any). Scaling-up treatment by treating all incarcerated persons irrespective of their sentence length provided maximum health benefits–preventing 10,200 new cases of HCV, and 8,300 HCV-related deaths between 2019–2050; 90% deaths prevented would have occurred in the community. Compared with status quo, this strategy increased quality-adjusted life year (QALYs) by 69,700 and costs by €670 million, yielding an incremental cost-effectiveness ratio of €9,600/QALY. Scaling-up HCV treatment with DAAs for the entire Spanish prison population, irrespective of sentence length, is cost-effective and would reduce HCV burden.

Hepatitis C Virus Prevalence, Screening, and Treatment Among People Who Are Incarcerated in Canada: Leaving No One Behind in the Direct‐Acting Antiviral Era

“…Several studies have demonstrated that scaling up HCV testing and treatment in correctional settings, or "microelimination" approaches, can reduce HCV transmission among PWID, both in prisons and the community, [23][24][25] and are demonstrated to be cost-effective. [26][27][28] "Treat all" approaches aiming to achieve microelimination of HCV infection in correctional settings are feasible, as demonstrated in Australian prisons, 29,30 the United States, 31 and Spain. 32 Because screening is the first step in HCV care, increasing uptake is crucial to improving care pathways for PWAI and may positively impact transition into the community 33 ; therefore, universal STBBI screening at intake should be implemented, as has been done by CSC and in Alberta.…”

“…Several studies have demonstrated that scaling up HCV testing and treatment in correctional settings, or “microelimination” approaches, can reduce HCV transmission among PWID, both in prisons and the community, 23‐25 and are demonstrated to be cost‐effective 26‐28 . “Treat all” approaches aiming to achieve microelimination of HCV infection in correctional settings are feasible, as demonstrated in Australian prisons, 29,30 the United States, 31 and Spain 32 .…”

Cost effectiveness of direct acting antivirals in the treatment of hepatitis C in vulnerable populations

“…An important limitation of the CE model is that it does not incorporate individuals' transition to communities. A separate study by Dalgic et al assessed the CE of HCV therapy in Spain's prisons [11]. The model considered a number of important variables such as viral transmission and prison-community dynamics.…”

“…Studies have consistently shown the use of DAAs against HCV to be cost-effective [10][11][12][13][14][15][16][17][18]. These studies differ in the country of origin, base populations, comparative treatment groups, and a variety of assumptions such as reinfection rates (See Table 1).…”

Considering treatment-as-prevention scale-up for Australian prisons: a qualitative sub-study of expert stakeholders from the Australian ‘surveillance and treatment of prisoners with hepatitis C’ project (SToP-C)

“…Prisoner populations’ high viral prevalence, combined with tight prison regulation and limited harm reduction measures make for an opportune and advantageous setting for a real-world trial [ 16 , 17 ]. Despite demonstrations of its feasibility within mathematical modeling work [ 1 , 18 , 19 ], limited empirical data exist regarding HCV treatment-as-prevention in real-world prison settings. The Australian ‘Surveillance and Treatment of Prisoners with Hepatitis C’ project (SToP-C) [ 20 ] is the world’s first implementation trial of HCV treatment scale-up as prevention in prison.…”