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.

Conclusion

Hepatitis C testing campaigns can be effective in finding and diagnosing people with hepatitis C infection, particularly those disengaged with care. The costs associated with finding and diagnosing people with hepatitis C infection (and ensuring they have a completed testing event) represent a substantial proportion of the overall hepatitis C care cascade costs. If financial incentives can improve retention in care, even modestly, particularly in settings or population groups with high rates of loss to follow-up, they are likely to deliver better testing and treatment outcomes for the same unit costs.

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Funding information
National Health and Medical Research Council; Gilead Sciences

Abbreviations
A$, Australian dollars; DAA, direct-acting antiviral; EC, Eliminate Hepatitis C; PWID, people who inject drugs; RNA, Ribonucleic acid; WHO, World Health Organization.

Acknowledgements
The authors gratefully acknowledge the participating services in the project—Access Health, cohealth Innerspace, cohealth Healthworks and Mediclinic—and the support from Harm Reduction Victoria and Hepatitis Victoria/LiverWELL. The authors also acknowledge the support to the Burnet Institute provided by the Victorian Government Operational Infrastructure Support Program. The Eliminate Hepatitis C Victoria Partnership is funded through an NHMRC partnership grant, with additional funding provided by Gilead Sciences.

Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Table 1. Line-listed costs from the EC Testing Campaign, including sources and calculations, of items included in the analysis (AUD$)
	Estimate	Source/calculation
Campaign pre-event costs
Central coordination costs
Staff planning the event time	$7200	EC campaign, estimate of 160 h of nurse staff time across multiple staff
Staff coordinating time with each site	$4500	EC campaign, estimate of 100 h of nurse staff time
Travel cost to each site	$320	EC campaign, car hire estimate of $80 per day
Partner organization costs
Harm Reduction Staffing time	$1680	EC campaign–40 h at $42 per hour
Hepatitis Victoria staffing time	$1680	EC campaign–40 h at $42 per hour
Promotional material and merchandise
Posters	$240	EC campaign
Business Cards	$100	EC campaign
Fit pack Stickers	$400	EC campaign
T- Shirts	$1800	EC campaign
Merchandise - fit pack cases	$72	EC campaign
Training
EC staff providing Hep C training to NSP workers	$540	EC campaign–12 h of nurse practitioner time
Total campaign pre-event costs	$18,532	Sum of pre-event costs
Campaign event costs
Staffing costs
Harm Reduction Staffing time	$1344	EC campaign, 32 h at $42 per hour
Hepatitis Victoria staffing time	$1344	EC campaign, 32 h at $42 per hour
Nursing staffing time	$3240	EC campaign, 72 h of nurse practitioner time
Nursing staff travel cost	$720	EC campaign, car hire estimate of $80 per day
Catering & incentives
Catering per site	$2700	EC campaign
Reimbursement to attendees for undergoing testing per site	$2000	EC campaign – approximately $20 per person for testing, or referring a friend for testing. Varied by site
Testing equipment
Butterfly Vacutainer needle (box of 50)	$387.52	Pathology provider
Gloves (box of 100)	$18.40	Pathology provider
Blood tubes	$200.00	Pathology provider
Needle holder (bag of 250)	$192.00	Pathology provider
Cotton balls (box of 60)	$12.76	Pathology provider
Alcohol Swabs (box of 100)	$24.40	Pathology provider
Courier cost	$270.00	Pathology provider
FibroScan costs
Machine cost	$70,686	Supplier Quote
Machine lifetime	7	Supplier Quote
Maintenance cost (per year)	$11,550	Supplier Quote
Average number of days FibroScan used per year	200	Nurse practitioner estimate
Cost of FibroScan usage	$974	([1/7]*Machine cost + maintenance)/200 gave the cost per day, multiplied by 9 event days
Total campaign event costs	$13,427	Sum of event costs
Testing-specific costs
Hepatitis C pathology
Hepatitis C antibody serology	$15.65	MBS* #69475 (only applies to those without known antibody status)
Hepatitis C RNA quantification	$180.25	MBS#69488 (only applies antibody-positive people)
Staff and communication costs
Nurse practitioner hourly salary	$45	Fair Work Ombudsman Pay Guide Award 2010 (Registered nurse, level 5, pay point 4)
Nurse time to review test results (all)	5 min	Nurse practitioner estimate
Nurse time to contact RNA-negative attendee	5 min	Nurse practitioner estimate
Nurse time to contact RNA-positive attendee	30 min	Nurse practitioner estimate (longer than following up negative person since following up positive person was deemed more important)
SMS/letter communication cost per person	$1	EC campaign
Testing cost for Ab- person	$24.15	Antibody serology + 10 min nurse time + communication
Testing cost for Ab+, RNA- person	$201.65	Antibody serology × 82% + RNA quantification + 10 min nurse time + communication
Testing cost for RNA + person	$220.40	Antibody serology × 82% + RNA quantification + 35 min nurse time + communication
Total testing-specific costs	$14,895	Sum of testing costs for 22 Ab-, 45 Ab + RNA-, 24 RNA + attendees
Treatment costs
Hepatitis C pathology costs
Hepatitis C genotype	$204.00	MBS #69491 (only applies to PCR-positive attendees)
Total genotyping costs	$4896	Sum of genotype test for 24 RNA + attendees
Pre-treatment work up
Liver function tests and urea electrolytes and creatinine	$17.70	MBS#66512
Full blood examination	$16.65	MBS#65070
HIV and hepatitis B serology	$29.00	MBS#69387
International normalized ratio	$13.70	MBS#65120
Total pathology costs	$5,316	Sum of pre-treatment work up for 69 Ab + attendees
Staff costs
Nurse practitioner hourly salary	$45	Fair Work Ombudsman Pay Guide Award 2010 (Registered nurse, level 5, pay point 4)
Nurse time to discuss treatment with PCR-positive person	45 min	Nurse practitioner estimate
Total nurse time to initiate treatment	$337.50	Sum of time for 10 attendees initiating treatment
Total treatment costs	$10,550	Sum of all treatment costs
Evaluation costs
Senior staffing costs	$1040	EC campaign–20 h at $52 per hour
Research assistant costs (to conduct exit surveys)	$336	EC campaign–8 h at $42 per hour
Total evaluation costs:	$1376	Sum of evaluation costs
Total Costs
Total testing cost	$48,230	Sum of pre-event, event, test specific and evaluation costs
Total treatment cost	$10,055	Treatment costs
Overall cost	$58,780	Sum of testing and treatment costs

*Medicare Benefits Schedule.

Table 2. Sensitivity analysis for (a) the cost per RNA-positive person completing testing (b) cost per RNA diagnosed person initiating treatment
(a) Cost per RNA + person completing testing		(b) Cost per RNA + person initiating treatment
Baseline	$3215	Baseline	$1055
Costs −10%	$2894	Costs −10%	$949
Costs +10%	$3537	Costs +10%	$1160
40% complete testing	$5024	40% initiate treatment	$1736
80% complete testing	$2512	80% initiate treatment	$885
10% of Ab + people are RNA positive	$11,110	10% of Ab + people are RNA positive	$2373
50% of Ab + people are RNA positive	$2246	50% of Ab + people are RNA positive	$893