title: 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: 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 assessed the cost-effectiveness of increased HCV case-finding and treatment in UK prisons using short-course therapies. 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 interferon (IFN)-free direct-acting antivirals (DAAs; 8-12 weeks, 95% sustained virological response, £3300/week). Costs (British pounds, £) and health utilities (quality-adjusted life years) were used to calculate mean incremental cost-effectiveness ratios (ICERs). We assumed 56% referral and 2.5%/25% of referred people who inject drugs (PWID)/ex-PWID treated within 2 months of diagnosis in prison. PWID and ex-PWID or non-PWID are in prison an average 4 and 8 months, respectively. Doubling prison testing rates with existing treatments produces a mean ICER of £19,850/quality-adjusted life years gained compared to current testing/treatment and is 45% likely to be cost-effective under a £20,000 willingness-to-pay threshold. Switching to 8-week to 12-week IFN-free DAAs in prisons could increase cost-effectiveness (ICER £15,090/quality-adjusted life years 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 with 8 weeks' duration.
  
  
  
  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 willingness to pay 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. (Hepatology 2016;63:1796-1808).
authors: Division of Global Public Health, University of California San Diego, San Diego, CA.|School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors: Natasha K
authors: NK
authors: Martin
authors: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors: Peter
authors: P
authors: Vickerman
authors: Leeds Community Healthcare NHS Trust, Leeds, UK.
authors: Iain F
authors: IF
authors: Brew
authors: Leeds Community Healthcare NHS Trust, Leeds, UK.
authors: Joan
authors: J
authors: Williamson
authors: London School of Hygiene and Tropical Medicine, London, UK.
authors: Alec
authors: A
authors: Miners
authors: University of Nottingham, Nottingham, UK.
authors: William L
authors: WL
authors: Irving
authors: County Durham and Darlington NHS Trust, Darlington, UK.
authors: Sushma
authors: S
authors: Saksena
authors: Glasgow Caledonian University, Glasgow, UK.
authors: Sharon J
authors: SJ
authors: Hutchinson
authors: Public Health England, London, UK.
authors: Sema
authors: S
authors: Mandal
authors: Public Health England, London, UK.
authors: Eamonn
authors: E
authors: O'Moore
authors: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors: Matthew
authors: M
authors: Hickman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000998:Antiviral Agents / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D006526:Hepatitis C / Q000175:diagnosis / Q000188:drug therapy / Q000191:economics* / Q000453:epidemiology; D006801:Humans; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D008962:Models, Theoretical; D011329:Prisoners; D000072230:Sustained Virologic Response; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000998:Antiviral Agents