RESUMO
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.
RESUMO
BACKGROUND: People in prison have been identified as an important population to prioritise for hepatitis C virus (HCV) treatment to achieve HCV elimination goals. We evaluated the efficacy of the New South Wales Justice Health and Forensic Mental Health Network Hepatitis Nurse Led Model of Care during the 12 months following the widespread availability of HCV direct acting antivirals (DAAs) in Australia. METHODS: A retrospective cohort study was conducted of a network of 36 correctional centres across NSW from April 2016 to March 2017, with approximately 13 000 full time inmates. Population Health Nurses conducted initial clinical assessments and confirmatory testing. Patients were referred to a Hepatitis Clinical Nurse Consultant (CNC) for protocol-driven assessment, including transient elastography to assess hepatic fibrosis. The CNC then discussed the case with an Infectious Diseases physician and DAA therapies were prescribed. The total number of patients who commenced and completed treatment, and sustained virological response 12 weeks post treatment completion (SVR 12) were recorded. RESULTS: During the first 12 months of DAA treatment 698 patients were commenced on HCV treatment. Of those who were tested at the 12-week post treatment completion timepoint the per-protocol SVR12 (cure) rate was 92% (396/430), with 34 patients having a detectable viral load. 52 (7%) patients were released to freedom before completing treatment and a further 211 (30%) were released prior to SVR12 assessment. These outcomes indicate an intention-to-treat SVR 12 cure rate of 57% (396/698). There were no differences in demographic or treatment characteristics between those who underwent SVR12 testing and those released prior. CONCLUSIONS: Treatment for HCV can be delivered safely, efficiently and in high numbers in the prison setting using a nurse-led model of care. This will be an important component of the strategy to eliminate HCV infection as a public health concern by 2030.
