A recent paper published in JAMA Network Open by researchers at the University of Utah and the University of Nebraska examined the dollars and cents of hepatitis C virus (HCV) screening in the United States. Whereas universal screening for adults was not found to be cost-effective, their findings suggest that targeted screening for people who inject drugs could be an economical intervention.
Hepatitis C, a liver infection caused by HCV, is spread through exposure to blood or bodily fluids that contain blood from an infected individual. For some, hepatitis C is a short-lived illness, but for more than half of those infected it becomes a long-term, chronic infection that can result in severe and even life-threatening health issues such as cirrhosis and liver cancer.
As many as 3.5 million people are living with chronic HCV infection in the United States, said lead author Moosa Tatar, MA, Visiting Scholar at the University of Utah’s Department of Population Health Sciences. HCV is one of the most common indications for liver transplantation, he told First Report Managed Care, which is one of the most expensive medical procedures performed in the United States.
Unfortunately, a majority of those with HCV infection are not aware of it, he added. Symptoms aren’t always evident in the early stages, and when they do appear, symptoms are often a sign of advanced liver disease. Screening is crucial, he said, and it is preferable to start with high-risk populations when considering how to best utilize limited financial and health care resources.
Although most people with chronic HCV infections in the United States are older adults born between 1946 and 1964, the opioid epidemic has led to an evolving epidemiology as the incidence among adults younger than 40 years has grown. Sharing needles among people who inject drugs is a critical factor for transmission, Mr Tatar said, especially in prisons and jails, where infection rates are far higher than the general US population. Inmates in correctional institutions account for as much as one-third of all US hepatitis C cases.
HCV treatments are highly effective, he added, particularly if caught in the early stages of infection. But few studies examining the cost-effectiveness of screening in the United States have taken into account the latest treatment regimens for HCV, he and colleagues noted. To address this apparent gap, the researchers compared the cost-effectiveness of targeted screening for people who inject drugs with a universal screening program for United States adults while considering the most recent and effective treatments for HCV, which costs roughly half the price of older treatments, according to the study.
Cost-Effectiveness for Targeted vs Universal Screening
In their study, the authors presented incremental cost-effectiveness ratios representing the estimated cost per additional life-year gained. Assuming HCV prevalence is 1% in the general population and 60% among people who inject drugs, they concluded that targeted screening of people who inject drugs is a cost-effective option (with an incremental cost-effectiveness ratio of $45,465) for combating HCV infection in the United States.
The microsimulation results for a people who inject drugs population revealed that screening and treatment were associated with the prevention of at least 88 deaths and a reduction in new infections by over 8700 cases compared to the status quo. In addition, screening people who inject drugs for HCV was associated with 18 fewer liver transplantations. Universal screening, however, was not found to be cost-effective based on their analysis (with an incremental cost-effectiveness ratio of $291,277).
Considering the high prevalence of HCV infection among people who inject drugs, the authors concluded that diagnosing and treating infection in its early stages among this particular population could prevent many HCV-related complications, ward off premature fatalities, and significantly reduce health care expenditures in the United States.
There are several limitations to these findings, however, the researchers acknowledged. Potential reinfection was assumed to be 1% in their model, which is the probability of infection for the general population, but reinfection rates are higher among people who inject drugs.
Also, their model included only direct medical costs even though indirect costs can be significant. These estimates were gathered from published sources that might not reflect the actual treatment costs for a certain region or particular medical system. Furthermore, the modeling
assumes that individuals complete the full 2-month drug treatment regimen, if diagnosed.
Coauthor Mark Mailliard disclosed that he has received grants from Gilead Sciences and AbbVie outside of the submitted work. (AbbVie manufactures the glecaprevir and pibrentasvir treatment regimen included in the study’s analysis.)
Additional Context and Insight
Despite the concerning trends in HCV incidence, treatment advances have led to several highly effective therapy regimens that could alter the current course of this epidemic, Eric W Hall, PhD, MPH with Emory University’s department of epidemiology and Heather Bradley, PhD, MHS, with Georgia State University’s department of epidemiology and biostatistics, noted in a related JAMA Network Open commentary piece. The underdiagnoses of infections and the increasing incident infections combined with the availability of curative treatment suggest the need for more screening moving forward.
Previous research centered on HCV screening in the United States has led to mixed results, however. Some studies have not supported widespread screening for average-risk adults, whereas other research has indicated that broad screening for the general population can, indeed, be a cost-effective approach.
The study by Tatar and colleagues is part of this growing body of research that helped inform a recent update to US Centers for Disease Control and Prevention (CDC) guidelines, they explained. Before this update, CDC recommended HCV screening for people born between 1945 and 1965 and for people with known risk factors, including injection drug use. Earlier this year, though, CDC updated its guidance to include two new recommendations: a one-time screening of all adults and the screening of all pregnant women, except in settings where HCV prevalence is less than 0.1%.
According to Drs Hall and Bradley, the cost-effectiveness analysis framework utilized by Tatar and colleagues is a crucial part of the development of public health recommendations and policies. Yet, it can be a challenge to compare the epidemiologic representation of a health condition. The most influential inputs in cost-effectiveness models of public health interventions are often basic measures of disease frequency, they explained. For many infectious diseases, these measures are estimated using surveillance data, but HCV incidence estimates are lacking and approximations for high-risk populations, such as for people who inject drugs, are “even less reliable.”
As the HCV epidemic continues to evolve, they said there is a need for improved data to make possible the standardized modeling of potential intervention outcomes. Meanwhile, cost-effectiveness researchers should continue to present a wide range of scenarios and analyses on the basic measures that inform their models, they added, and policymakers reviewing this research should critically evaluate model assumptions and the generalizability to their population of interest.