The Testing of People With Any Risk Factor for Hepatitis C in Community Pharmacies is Cost-effective

Ryan Buchanan; Keith Cooper; Leonie Grellier; Salim I. Khakoo; Julie Parkes

Disclosures

J Viral Hepat. 2019;27(1):36-44. 

In This Article

Abstract and Introduction

Abstract

New antiviral drugs with high efficacy mean the hepatitis C virus (HCV) can now be eliminated. To achieve this, it is necessary to identify undiagnosed cases of HCV. However, the costs of testing should be considered when judging the overall cost-effectiveness of treatment. This study describes the cost-effectiveness of a community pharmacy testing service in a population of people at risk of HCV living on the Isle of Wight (United Kingdom). Dry blood spot testing was conducted in anyone with a known risk factor for HCV in 20 community pharmacies. The outcomes and costs were entered into a Markov model. Cost and health utilities from the model were used to calculate an incremental cost-effectiveness ratio (ICER). In 24 months, 186 tests were conducted, 13 were positive for HCV RNA and six of these (46%) received treatment during the follow-up period. All achieved a sustained virological response at 3 months. The overall cost of the testing and treatment intervention was £242 183, and the ICER for the service was £3689 per quality-adjusted life year (QALY) gained. If screening had been restricted to just people with a history of injecting drug use (PWID) the ICER would have been £4865 per QALY gained. The service was effective at identifying people with HCV infection, and despite the additional cost of targeted testing, its cost-effectiveness was below the commonly accepted thresholds. In this setting, restricting targeted testing to PWID would not improve the cost-effectiveness.

Introduction

Hepatitis C (HCV) is a small RNA virus that usually causes chronic hepatitis in infected humans.[1] In some cases, this can progress to liver cirrhosis and hepatocellular carcinoma[2] and the virus is therefore a significant cause of global mortality.[3] However, in recent years, new therapies for HCV have been developed which directly target the virus and achieve an effective cure in over 90% of treated patients.[4,5]

The dramatic progress in drug therapy for HCV has resulted in the World Health Organization (WHO) setting a target for global elimination of HCV by 2030.[6] According to the WHO in order to meet the definition for elimination, 90% of prevalent HCV cases need to be identified and treatment administered to 80% of these.[7]

Chronic HCV often causes nonspecific symptoms, and therefore, many cases worldwide are undiagnosed.[2] Most infections in the United Kingdom (UK) are in people with a history of injecting drug use, and up to 50% of these individuals are not aware they are infected.[8] Case finding for prevalent HCV therefore needs to form a major part of the international approach to achieving HCV elimination.

The Centre for Disease Control in the United States of America (USA) has recommended cohort screening for HCV in the 'baby-boomer' generation.[9] However, in the UK and most other countries, a more targeted testing approach is recommended. According to the National Institute for Health and Care Excellence (NICE) in the UK, this comprises persons with a range of risk factors including people who currently or have previously injected drugs, people who received potentially infected blood products and people from areas with a high background prevalence of HCV.[10]

In order to meet the international target for HCV elimination, the number of undiagnosed cases needs to be reduced and, therefore, case-finding practices need to adapt. Unfortunately, there remain numerous barriers to testing that need to be overcome.[11–14] Attempts have been made to address these; in the UK, national action plans have encouraged an increase in HCV testing and this has prompted initiatives such as primary care record screening for people at risk of HCV, testing in emergency departments, and prisons and widespread testing in drug support centres.[15–18] In addition to these initiatives, there is also growing evidence that targeted testing for HCV in community pharmacies may be an effective approach to identify undiagnosed cases of HCV.[19–21]

However, treatment for HCV is expensive and when the costs of the directly acting antiviral drugs (DAAs) are assessed against potential benefits, they have been close to acceptable 'willingness to pay' thresholds in the USA,[22] UK[23] and Europe.[24] It is therefore important that the additional costs associated with pharmacy-based testing are considered for this service develop further. To address this, we report outcomes from a 24-month study of HCV targeted testing in community pharmacies in a UK population and present a cost-effectiveness analysis that accounts for the additional costs of testing.

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