title: Prioritization of HCV treatment in the direct-acting antiviral era: An economic evaluation.
abstract: We determined the optimal HCV treatment prioritization strategy for interferon-free (IFN-free) HCV direct-acting antivirals (DAAs) by disease stage and risk status incorporating treatment of people who inject drugs (PWID).
  
  
  
  A dynamic HCV transmission and progression model compared the cost-effectiveness of treating patients early vs. delaying until cirrhosis for patients with mild or moderate fibrosis, where PWID chronic HCV prevalence was 20, 40 or 60%. Treatment duration was 12weeks at £3300/wk, to achieve a 95% sustained viral response and was varied by genotype/stage in alternative scenarios. We estimated long-term health costs (in £UK=€1.3=$1.5) and outcomes as quality adjusted life-years (QALYs) gained using a £20,000 willingness to pay per QALY threshold. We ranked strategies with net monetary benefit (NMB); negative NMB implies delay treatment.
  
  
  
  The most cost-effective group to treat were PWID with moderate fibrosis (mean NMB per early treatment £60,640/£23,968 at 20/40% chronic prevalence, respectively), followed by PWID with mild fibrosis (NMB £59,258 and £19,421, respectively) then ex-PWID/non-PWID with moderate fibrosis (NMB £9,404). Treatment of ex-PWID/non-PWID with mild fibrosis could be delayed (NMB -£3,650). In populations with 60% chronic HCV among PWID it was only cost-effective to prioritize DAAs to ex-PWID/non-PWID with moderate fibrosis. For every one PWID in the 20% chronic HCV setting, 2 new HCV infections were averted. One extra HCV-related death was averted per 13 people with moderate disease treated. Rankings were unchanged with reduced drug costs or varied sustained virological response/duration by genotype/fibrosis stage.
  
  
  
  Treating PWID with moderate or mild HCV with IFN-free DAAs is cost-effective compared to delay until cirrhosis, except when chronic HCV prevalence and reinfection risk is very high.
authors: Division of Global Public Health, University of California San Diego, San Diego, USA; School of Social and Community Medicine, University of Bristol, UK. Electronic address: Natasha-martin@ucsd.edu.
authors: Natasha K
authors: NK
authors: Martin
authors: School of Social and Community Medicine, University of Bristol, UK.
authors: Peter
authors: P
authors: Vickerman
authors: Kirby Institute, UNSW Australia, Sydney, Australia.
authors: Gregory J
authors: GJ
authors: Dore
authors: Kirby Institute, UNSW Australia, Sydney, Australia.
authors: Jason
authors: J
authors: Grebely
authors: Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK.
authors: Alec
authors: A
authors: Miners
authors: Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK.
authors: John
authors: J
authors: Cairns
authors: Queen Mary's University of London, UK.
authors: Graham R
authors: GR
authors: Foster
authors: Glasgow Caledonian University, UK; Health Protection Scotland, UK.
authors: Sharon J
authors: SJ
authors: Hutchinson
authors: Glasgow Caledonian University, UK; Health Protection Scotland, UK.
authors: David J
authors: DJ
authors: Goldberg
authors: Guy's and St Thomas's NHS Foundation Trust, London, UK.
authors: Thomas C S
authors: TCS
authors: Martin
authors: Public Health England, UK.
authors: Mary
authors: M
authors: Ramsay
authors: School of Social and Community Medicine, University of Bristol, UK.
authors: Matthew
authors: M
authors: Hickman
mesh_terms: D000998:Antiviral Agents; D003362:Cost-Benefit Analysis; D006526:Hepatitis C; D006801:Humans; D007372:Interferons; D000072230:Sustained Virologic Response
chemical_list: D000998:Antiviral Agents; D007372:Interferons
keywords: Hepatitis C; People who inject drugs; Prevention; Treatment