Cost-effectiveness and Budgetary Impact of Hepatitis C Virus Testing, Treatment, and Linkage to Care in US Prisons

Abstract

Background: Hepatitis C virus (HCV) testing and treatment uptake in prisons remains low. We aimed to estimate clinical outcomes, cost-effectiveness (CE), and budgetary impact (BI) of HCV testing and treatment in United States (US) prisons or linkage to care at release.

Methods: We used individual-based simulation modeling with healthcare and Department of Corrections (DOC) perspectives for CE and BI analyses, respectively. We simulated a US prison cohort at entry using published data and Washington State DOC individual-level data. We considered permutations of testing (risk factor based, routine at entry or at release, no testing), treatment (if liver fibrosis stage ≥F3, for all HCV infected or no treatment), and linkage to care (at release or no linkage). Outcomes included quality-adjusted life-years (QALY); cases identified, treated, and cured; cirrhosis cases avoided; incremental cost-effectiveness ratios; DOC costs (2016 US dollars); and BI (healthcare cost/prison entrant) to generalize to other states.

Results: Compared to "no testing, no treatment, and no linkage to care," the "test all, treat all, and linkage to care at release" model increased the lifetime sustained virologic response by 23%, reduced cirrhosis cases by 54% at a DOC annual additional cost of $1440 per prison entrant, and would be cost-effective. At current drug prices, targeted testing and liver fibrosis-based treatment provided worse outcomes at higher cost or worse outcomes at higher cost per QALY gained. In sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs.

Conclusions: Although costly, widespread testing and treatment in prisons is considered to be of good value at current drug prices.

Keywords: budgetary impact; computer simulation model; cost-effectiveness; hepatitis C; prisons.

Figure 1.

Cost-effectiveness frontier for hepatitis C virus infection testing and treatment in prisons. The figure illustrates the effectiveness, cost, and incremental cost-effectiveness of all 15 strategies considered. The color of each shape represents alternative testing approaches (no testing, testing by risk factors, testing all at entry, and testing all at release). Shapes (circles vs triangles) represent whether linkage to care is included in the strategy. The size of the shape represents alternative treatment approaches (no treatment, treatment if liver fibrosis stage ≥F3, and treatment for all). Strategies located to the right of the efficiency frontier result in either lower quality-adjusted life expectancy at higher cost than an alternative strategy or a higher cost per quality-adjusted life-year gained. Strategies testing all at entry to prison provide better clinical outcomes than other testing approaches. “Test all, treat all, and linkage to care at release” also improves outcomes. The 2 strategies located on the cost-effectiveness frontier are “test and treat all with or without linkage to care.”

Figure 2.

Sensitivity analysis for per-person 1-year budgetary impact from the prison perspective. The figure shows the influence of decreased drug price on the cost per person admitted to the prison. The green shape represents the “test all, treat all, and linkage to care at release” strategy. The blue shape shows the “test all, treat ≥F3, and linkage to care at release” strategy. For “test all, treat all, and linkage to care at release,” the per-person additional cost compared to current practice fell from $3030/person to $1440/person when drug prices were decreased. For “test all, treat ≥F3, and linkage to care at release,” there was only a modest change from $630/person to $550/person.