Systematic Review

Economic Evaluations of HCV Screening in the Direct-acting Antivirals Era

Paolo Angelo Cortesi; Roberta Barca; Giulia Giudicatti; Sergio Mossini; Antonio Ciaccio; Sergio Iannazzo; Mariangela Micale; Giancarlo Cesana; Lorenzo Giovanni Mantovani

Disclosures

Aliment Pharmacol Ther. 2019;49(9):1126-1133. 

In This Article

Abstract and Introduction

Abstract

Background: The World Health Organization estimated that 90% of the infected people need to be diagnosed and 80% need to be treated to reach the aim of hepatitis C virus (HCV) elimination by 2030. For this reason, all possible strategies to detect and treat HCV-infected people need to be carefully evaluated to implement the best one.

Aim: To review and synthesise the economic evaluations of HCV screening programs conducted in the era of direct-acting antiviral agents regimens.

Methods: A systematic literature review was conducted until April 2018 to provide information on the costs and effectiveness of HCV screenings in direct-acting antiviral agents era. A critical assessment of the quality of economic evaluations retrieved was conducted.

Results: The literature search identified 716 references; 17 of them assessed cost and effectiveness of screening programs and antiviral treatments in different populations: general population (n = 7), drug users (n = 5), high-risk populations (n = 4) and other populations (n = 3). The HCV screening and direct-acting antiviral agents treatment appear to be good value for money, both in general and high-risk populations, if a cost per quality adjusted life years of $50 000 is set as willingness to pay threshold. Some studies showed the value of including lower stage of fibrosis in the treatment selection criteria.

Conclusions: Several HCV screening strategies plus direct-acting antiviral agents treatments resulted cost-effectiveness in different populations. However, there is still need of country and population-specific evaluations within the different HCV screening and treatment strategies available, in order to assess their cost-effectiveness and sustainability and fully support an evidence-informed policy for HCV elimination.

Introduction

Viral hepatitis C (HCV) is a major public health problem in need of urgent responses.[1–3] According to the latest estimation, 71 million people have chronic hepatitis C infection,[4] accounting for almost 600 000 deaths.[1] Even though the higher number of diagnosed patients, the HCV and HCV related diseases remains relatively unknown amongst the general public and medical professionals.[4]

Identification of HCV infection is often delayed due to their asymptomatic course until the development of complications.[5] Approximately 25% of patients with chronic HCV progress to advanced liver diseases including cirrhosis that can lead to Hepatocellular carcinoma.[6] In the Western word, HCV is responsible for more than 50% of all Hepatocellular carcinoma and two-thirds of liver transplants.[2,7]

In the last few years, we have witnessed a revolution in HCV treatment. The suboptimal standard therapy with pegylate interferon plus ribavirin has been replaced by direct-acting antiviral agents (DAAs) regimens.[8] DAAs reported a sustained virologic response probability >95% across different genotypes and patient populations[9] with an optimal safety profile compared to a sustained virologic response of 50% reported by pegylate interferon plus ribavirin in genotype 1 and 4 and 80% in genotype 2 or 3 with relevant safety issues.[10] This extraordinary treatment improvement has converted HCV infection into a curable disease, leading the World Health Organization to aim HCV elimination by 2030.[3] However, the World Health Organization estimated that 90% of the infected people need to be diagnosed and 80% need to be treated to reach this goal.[11]

Within this new scenario, identifying HCV has become a focus of public health programmers and many countries are assessing the possible strategies of HCV screening and management. In the last years, the high price of DAAs has limited the access to the treatment and increased national treatment-access policy based on disease stage;[12,13] indeed, only 1.76 million HCV people started treatment in 2016, with a modest increase compared to 1.1 million in 2015.[14] However, due to the price competition between different DAAs regimen, the treatment cost scenario is rapidly changing as are the national treatment-access policies.[15] Furthermore, discussion is still ongoing on the best HCV screening strategies in terms of effectiveness, costs and access;[16–18] considering also the new simplified approaches for screening, diagnosis and monitoring HCV infection that are now available and that are coming in the near future into the market.[16,17]

Considering the big challenge of HCV treatment access and sustainability, the complexity of HCV screening programs, with the need to improve HCV case finding strategies, and their relative cost, all the possible strategies to detect and treat HCV-infected people need to be carefully evaluated. Thus, the aim of this study was to review and synthesise the economic evaluations of HCV screening programs conducted in the era of DAAs to support evidence-informed policy for HCV elimination.

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