The cost-effectiveness of improved hepatitis C virus therapies in HIV/hepatitis C virus coinfected patients

Abstract

Objectives: To evaluate the effectiveness and cost-effectiveness of strategies to treat hepatitis C virus (HCV) in HIV/HCV coinfected patients in the United States.

Participants: Simulated cohort of HIV/HCV genotype 1 coinfected, noncirrhotic, HCV treatment-naive individuals enrolled in US HIV guideline-concordant care.

Design/interventions: Monte Carlo simulation comparing five strategies: no treatment; dual therapy with pegylated-interferon (PEG) and ribavirin (RBV); 'PEG/RBV trial' in which all patients initiate dual therapy and switch to triple therapy upon failure; 'IL28B triage' in which patients initiate either dual therapy or triple therapy based on their IL28B allele type; and PEG/RBV and telaprevir (TPV) triple therapy. Sensitivity analyses varied efficacies and costs and included a scenario with interferon (IFN)-free therapy.

Main measures: Sustained virologic response (SVR), life expectancy, discounted quality-adjusted life expectancy (QALE), lifetime medical costs, and incremental cost-effectiveness ratios (ICERs) in $/quality-adjusted life years (QALY) gained.

Results: 'PEG/RBV trial,' 'IL28B triage,' and 'triple therapy' each provided 72% SVR and extended QALE compared with 'dual therapy' by 1.12, 1.14, and 1.15 QALY, respectively. The ICER of 'PEG/RBV trial' compared with 'dual therapy' was $37 500/QALY. 'IL28B triage' and 'triple therapy' provided little benefit compared with 'PEG/RBV trial,' and both had ICERs exceeding $300 000/QALY. In sensitivity analyses, IFN-free treatment attaining 90% SVR had an ICER less than $100 000/QALY compared with 'PEG/RBV trial' when its cost was $109 000 or less (125% of the cost of PEG/RBV/TVR).

Conclusion: HCV protease inhibitors are most efficiently used in HIV/HCV coinfection after a trial of PEG/RBV, sparing protease inhibitors for those who attain rapid virologic response and SVR. The cost-effectiveness of IFN-free regimens for HIV/HCV coinfection will depend on the cost of these therapies.

Figure 1. Treatment strategy schematic

Simplified decision tree depicting the treatment strategies considered for treating HCV infection of HIV/HCV co-infected patients without cirrhosis. Note: figure layout was modeled after a similar figure by Liu et al. 2012 [67].

Figure 2. Tornado diagram “PEG/RBV trial” one-way sensitivity analyses

Tornado diagram illustrating the incremental cost effectiveness ratio (ICER) of the “PEG/RBV trial” strategy compared to its next best alternative when varying model input parameters through plausible ranges. Long bars demonstrate parameters that have a large impact on ICERs. Bars with a striped pattern illustrate parameters that led to the “PEG/RBV trial” strategy becoming dominated by either “IL28B triage” or “triple therapy”, meaning that the other option provided greater life expectancy at a lower cost per QALY gained. The white star indicates that the “PEG/RBV trial” strategy became dominated by “triple therapy.” The black star indicates that the “PEG/RBV trial” strategy became dominated by “IL28B triage.” The asterisk refers to Table 1 for base case values. (QALY= quality-adjusted life years; QoL= quality of life).

Figure 3. Two-way sensitivity analysis varying costs and efficacy of IFN-free therapy as an alternative to “PEG/RBV trial” strategy

Two-way sensitivity analysis comparing an IFN-free regimen as an alternative to the “PEG/RBV trial” strategy at various cost multipliers of the base case cost of PEG/RBV/TVR ($87,000-$175,000) and efficacies (80% SVR rate – 100% SVR rate). The striped boxes reflect an incremental cost effectiveness ratio (ICER) of “IFN-free” compared to “PEG/RBV trial” <$100,000/QALY, making “IFN-free” the preferred strategy. In contrast, the black boxes reflect an ICER of “IFN-free” compared to “PEG/RBV trial” >$100,000/QALY, making “PEG/RBV trial” the preferred strategy.