Scale-up of Direct-Acting Antiviral Treatment in Prisons Is Both Cost-effective and Key to Hepatitis C Virus Elimination

Sophy T F Shih; Jack Stone; Natasha K Martin; Behzad Hajarizadeh; Evan B Cunningham; Jisoo A Kwon; Colette McGrath; Luke Grant; Jason Grebely; Gregory J Dore; Andrew R Lloyd; Peter Vickerman; Georgina M Chambers

doi:10.1093/ofid/ofad637

Scale-up of Direct-Acting Antiviral Treatment in Prisons Is Both Cost-effective and Key to Hepatitis C Virus Elimination

Open Forum Infect Dis. 2023 Dec 18;11(2):ofad637. doi: 10.1093/ofid/ofad637. eCollection 2024 Feb.

Affiliations

¹ The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.
² Population Health Sciences, University of Bristol, Bristol, United Kingdom.
³ Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA.
⁴ Justice Health and Forensic Mental Health Network, New South Wales Health, Sydney, New South Wales, Australia.
⁵ Corrective Services New South Wales, Sydney, New South Wales, Australia.
⁶ National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia.

Abstract

Background: The Surveillance and Treatment of Prisoners With Hepatitis C (SToP-C) study demonstrated that scaling up of direct-acting antiviral (DAA) treatment reduced hepatitis C virus (HCV) transmission. We evaluated the cost-effectiveness of scaling up HCV treatment in statewide prison services incorporating long-term outcomes across custodial and community settings.

Methods: A dynamic model of incarceration and HCV transmission among people who inject drugs (PWID) in New South Wales, Australia, was extended to include former PWID and those with long-term HCV progression. Using Australian costing data, we estimated the cost-effectiveness of scaling up HCV treatment in prisons by 44% (as achieved by the SToP-C study) for 10 years (2021-2030) before reducing to baseline levels, compared to a status quo scenario. The mean incremental cost-effectiveness ratio (ICER) was estimated by comparing the differences in costs and quality-adjusted life-years (QALYs) between the scale-up and status quo scenarios over 40 years (2021-2060) discounted at 5% per annum. Univariate and probabilistic sensitivity analyses were performed.

Results: Scaling up HCV treatment in the statewide prison service is projected to be cost-effective with a mean ICER of A$12 968/QALY gained. The base-case scenario gains 275 QALYs over 40 years at a net incremental cost of A$3.6 million. Excluding DAA pharmaceutical costs, the mean ICER is reduced to A$6 054/QALY. At the willingness-to-pay threshold of A$50 000/QALY, 100% of simulations are cost-effective at various discount rates, time horizons, and changes of treatment levels in prison and community.

Conclusions: Scaling up HCV testing and treatment in prisons is highly cost-effective and should be considered a priority in the national elimination strategy.

Clinical trials registration: NCT02064049.

Keywords: DAA; HCV; economic evaluation; justice health; modeling.

Associated data

ClinicalTrials.gov/NCT02064049

Grants and funding

WT_/Wellcome Trust/United Kingdom