Cost and cost-effectiveness of a simplified treatment model with direct-acting antivirals for chronic hepatitis C in Cambodia.

BACKGROUND & AIMS: In 2016, Médecins Sans Frontières established the first general population Hepatitis C virus (HCV) screening and treatment site in Cambodia, offering free direct-acting antiviral (DAA) treatment. This study analysed the cost-effectiveness of this intervention. METHODS: Costs, quality adjusted life years (QALYs) and cost-effectiveness of the intervention were projected with a Markov model over a lifetime horizon, discounted at 3%/year. Patient-level resource-use and outcome data, treatment costs, costs of HCV-related healthcare and EQ-5D-5L health states were collected from an observational cohort study evaluating the effectiveness of DAA treatment under full and simplified models of care compared to no treatment; other model parameters were derived from literature. Incremental cost-effectiveness ratios (cost/QALY gained) were compared to an opportunity cost-based willingness-to-pay threshold for Cambodia ($248/QALY). RESULTS: The total cost of testing and treatment per patient for the full model of care was $925(IQR $668-1631), reducing to $376(IQR $344-422) for the simplified model of care. EQ-5D-5L values varied by fibrosis stage: decompensated cirrhosis had the lowest value, values increased during and following treatment. The simplified model of care was cost saving compared to no treatment, while the full model of care, although cost-effective compared to no treatment ($187/QALY), cost an additional $14 485/QALY compared to the simplified model, above the willingness-to-pay threshold for Cambodia. This result is robust to variation in parameters. CONCLUSIONS: The simplified model of care was cost saving compared to no treatment, emphasizing the importance of simplifying pathways of care for improving access to HCV treatment in low-resource settings.

Climate Change Drives Poleward Increases and Equatorward Declines in Marine Species.

Marine environments have increased in temperature by an average of 1°C since pre-industrial (1850) times [1]. Given that species ranges are closely allied to physiological thermal tolerances in marine organisms [2], it may therefore be expected that ocean warming would lead to abundance increases at poleward side of ranges and abundance declines toward the equator [3]. Here, we report a global analysis of abundance trends of 304 widely distributed marine species over the last century, across a range of taxonomic groups from phytoplankton to fish and marine mammals. Specifically, using a literature database, we investigate the extent that the direction and strength of long-term species abundance changes depend on the sampled location within the latitudinal range of species. Our results show that abundance increases have been most prominent where sampling has taken place at the poleward side of species ranges, and abundance declines have been most prominent where sampling has taken place at the equatorward side of species ranges. These data provide evidence of omnipresent large-scale changes in abundance of marine species consistent with warming over the last century and suggest that adaptation has not provided a buffer against the negative effects of warmer conditions at the equatorward extent of species ranges. On the basis of these results, we suggest that projected sea temperature increases of up to 1.5°C over pre-industrial levels by 2050 [4] will continue to drive latitudinal abundance shifts in marine species, including those of importance for coastal livelihoods.