A Modelling Analysis of Financial Incentives for Hepatitis C Testing and Treatment Uptake Delivered Through a Community-based Testing Campaign

Anna Y. Palmer; Kico Chan; Judy Gold; Chloe Layton; Imogen Elsum; Margaret Hellard; Mark Stoove; Joseph S. Doyle; Alisa Pedrana; Nick Scott

Disclosures

J Viral Hepat. 2021;28(11):1624-1634. 

In This Article

Abstract and Introduction

Abstract

Financial incentives may reduce opportunity costs associated with people who become lost to follow-up in hepatitis C treatment programs. We estimated the impact that different financial incentive amounts would need to have on retention in care to maintain the same unit cost per (1) RNA-positive person completing testing (defined as awareness of RNA status) and (2) RNA diagnosed person initiating treatment. Costing data were obtained from a 2019 community-based testing campaign focused on engaging people who inject drugs. For different financial incentive amounts, we modelled the corresponding improvements in retention in care that would be needed to maintain the same overall (1) unit cost per testing completion and (2) unit cost per treatment initiation. In the testing campaign, the unit cost per RNA-positive person completing testing was A$3215 and the unit cost per RNA diagnosed person initiating treatment was A$1055. Modelling found that an incentive of A$500 per RNA-positive person completing testing would result in more people completing testing for the same unit cost if the percentage of attendees receiving their test results increased from 63% to 74%. An incentive of A$200 per RNA diagnosed person initiating treatment would result in more people initiating treatment for the same unit cost if the percentage initiating treatment increased from 67% to 83%. Monetary incentives for completing testing and initiating treatment may be an effective way to increase retention in care without increasing the overall unit cost of completing testing/initiating treatment.

Introduction

Hepatitis C elimination is now a realistic public health goal, due to the advent of direct-acting antiviral (DAA) treatment for hepatitis C infection.[1] DAA treatments are well tolerated and effective, with cure being possible within 8–12 weeks.[2–4] In response, the World Health Organization (WHO) has set hepatitis C elimination targets of an 80% reduction in incidence and a 65% reduction in mortality by 2030.[5] To achieve these targets, the Australian government invested A$1.2 billion for an unlimited number of DAAs between 2016 and 2021,[6] and relaxed prescribing policies to allow general practitioners and trained nurse practitioners to prescribe DAAs in primary care.[7] Despite this, recent reports show that the number of people initiating treatment is declining,[8] putting Australia at risk of not meeting the WHO 2030 elimination targets.[9] Hence, new approaches to help engage and support people with hepatitis C into care are needed.[10]

Community-based interventions have formed a major part of Australia's hepatitis C elimination program success. Previous work has shown that community-based care is more effective than traditional hospital-based care in initiating diagnosed individuals on treatment,[11] and that community-based care is more cost-effective.[12] Community-based health services also play an important role in engaging new or previously disengaged clients for hepatitis C testing—particularly people who inject drugs (PWID), who are a high priority population for testing and treatment.[13]

One approach community-based health services have used are service-level hepatitis C testing campaigns, which typically involve advertising, catering, peer-based outreach, onsite testing and/or financial incentives to promote testing and linkage to care at the clinic.[14–16] Controlled trials have shown that financial incentives can increase hepatitis B vaccination rates among PWID,[17–19] suggesting that they could be effective in hepatitis C treatment programs that target PWID. However, the motivation and effort required to complete a hepatitis B vaccination may be quite different to that required to undertake hepatitis C treatment, and only a few hepatitis C programs have trialled small financial incentives (~A$10–20 per test/visit) for attendance at follow-up appointments during hepatitis C care.[20–23] Thus, it is unclear how incorporating financial incentives along the care cascade specifically influences testing, treatment initiation and treatment adherence.

Currently, incentive amounts used in feasibility studies to encourage testing and treatment uptake represent a trivial proportion of the overall costs of the programs, and hardly cover the cost of public transport or parking for clients to attend the clinic. Thus, increasing monetary incentives for clients may further encourage testing and treatment initiation. Moreover, if financial incentives were effective in increasing retention in care, the additional cost of including financial incentives in programs could be offset by the reduced opportunity costs associated with people who are lost from care, leading to the same unit cost per person tested/treated through the program (Figure 1). To assess what expenditure on incentives would be reasonable from an economic perspective, it is useful to estimate an incentive 'threshold', where the incentive reduces loss to follow-up and associated opportunity costs sufficiently such that the unit cost per person tested/treated remains the same. This evidence will help design future incentive programs by providing guidance on the potential cost and benefit of a range of incentives.

Figure 1.

Conceptual diagram illustrating (a) the cost per person treated (broken down by treatment initiation costs, costs associated with 'lost clients' and incentives costs) and (b) the potential effect of providing incentives for treatment initiation on the number of people treated. The number of people initiating treatment increases with incentives, while the unit cost per person initiating treatment remains the same

Using data from a previous study,[16] we estimated the average cost per RNA-positive person completing testing and the average cost per RNA diagnosed person initiating treatment through a community-based testing campaign. Based on this information, we then modelled the improvement in retention in care required for different monetary incentive amounts that would maintain the same[1] unit cost per RNA-positive person completing testing and[2] unit cost per RNA diagnosed person initiating treatment.

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