Is increased hepatitis C virus case‐finding combined with current or 8‐week to 12‐week direct‐acting antiviral therapy cost‐effective in UK prisons? A prevention benefit analysis

Abstract

Background Prisoners have a high prevalence of Hepatitis C virus (HCV), but case-finding may not have been cost-effective because treatment often exceeded average prison stay combined with a lack of continuity-of-care. We assess the cost-effectiveness of increased HCV case-finding and treatment in UK prisons using short-course therapies. Methods A dynamic HCV transmission model assesses the cost-effectiveness of doubling HCV case-finding (achieved through introducing opt-out HCV testing in UK pilot prisons) and increasing treatment in UK prisons, compared to status-quo voluntary risk-based testing (6% prison entrants/year), using currently recommended therapies (8–24 weeks) or IFN-free DAAs (8–12 weeks, 95% SVR, £3300/wk). Costs (GBP£) and health utilities (quality-adjusted life-years, QALYs) were used to calculate mean incremental cost-effectiveness ratios (ICERs). We assume 56% referral and 2.5%/25% of referred people who inject drugs (PWID)/exPWID treated within 2 months of diagnosis in prison. PWID and ex/nonPWID are in prison an average 4/8 months, respectively. Results Doubling prison testing rates with existing treatments produces a mean ICER of £19,850/QALY gained compared to current testing/treatment, and is 45% likely to be cost-effective under a £20,000 willingness-to-pay (WTP) threshold. Switching to 8–12 week IFN-free DAAs in prisons could increase cost-effectiveness (ICER £15,090/QALY gained). Excluding prevention benefit decreases cost-effectiveness. If >10% referred PWID are treated in prison (2.5% base-case), either treatment could be highly cost-effective (ICER<£13,000). HCV case-finding and IFN-free DAAs could be highly cost-effective if DAA cost is 10% lower or 8 weeks duration. Conclusions Increased HCV testing in UK prisons (such as through opt-out testing) is borderline cost-effective compared to status-quo voluntary risk-based testing under a £20,000 WTP with current treatments, but likely to be cost-effective if short-course IFN-free DAAs are used, and could be highly cost-effective if PWID treatment rates were increased.

Public health and international drug policy

“…For this Thailand-like scenario, the model estimates 53% of incident infections could occur in prison; HCV incidence could be 60% lower if incarceration had no effect on HCV transmission, and 94% lower with high coverage of prison OST and no increased risk following release (Figure 18). This analysis, although illustrative, highlights that incarceration could contribute substantially to HCV transmission among PWID and supports a growing body of evidence that interventions to reduce HCV risk among PWID in prison and post-release (such as OST and possibly HCV treatment) 226 could result in substantial benefits to the community and reduction in HCV transmission.…”

“…According to our results, interventions that aim to reduce transmission risk in prison (such as OST and possibly HCV treatment) 225,226 or post-release could substantially reduce HCV incidence among PWID. Figures 17 and 18 illustrate this point, using modelling undertaken by Commissioner Peter Vickerman and colleagues Jack Stone and Natasha Martin to consider the role of incarceration on HCV transmission among PWID in four illustrative scenarios (similar to Scotland, Australia, Ukraine and Thailand), chosen to mimic important PWID incarceration characteristics of varied global settings.…”

“…241 The much shorter duration of DAA therapies may make them more attractive in prisons, and a recent UK-based cost-effectiveness analysis indicates that HCV testing and treatment with short-course DAA therapy is cost-effective. 226 One middle-income country that has made a breakthrough is Georgia, which struck a deal with Gilead Sciences for concessionary pricing on its DAA sofosbuvir and decided to include free treatment for people in prison who need it. 244 …”

Modelling the impact of incarceration and prison-based hepatitis C virus (HCV) treatment on HCV transmission among people who inject drugs in Scotland

“…HCV treatment for incarcerated PWID, especially with shorter direct-acting antivirals (DAAs(16)), could reduce HCV transmission in prison and the community. However, although modelling suggests testing and treatment with DAAs could be cost-effective in UK prisons(17), HCV treatment in prison remains low(11). …”

Hepatitis C Prevalence and Responses to Pegylated Interferon + Ribavirin Treatment Among Prisoners

“…This emphasizes the importance of a cost-benefit analysis regarding the use of DAAs in prisoners (3). The cost analysis model developed by Martin et al (28) showed that IFN-free treatments may be cost-effective. Their model included 12-week sofosbuvir+RBV therapy for genotype 3 patients.…”