Nick Scott1, Joseph S Doyle2, David P Wilson3, Amanda Wade4, Jess Howell5, Alisa Pedrana3, Alexander Thompson6, Margaret E Hellard7. 1. Burnet Institute, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC 3008, Australia. Electronic address: Nick.Scott@burnet.edu.au. 2. Burnet Institute, Melbourne, VIC 3004, Australia; Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC 3004, Australia. 3. Burnet Institute, Melbourne, VIC 3004, Australia. 4. Burnet Institute, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC 3008, Australia. 5. Burnet Institute, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC 3008, Australia; Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia; Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, VIC 3165, Australia. 6. Department of Medicine, The University of Melbourne, Parkville, VIC 3050, Australia; Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, VIC 3165, Australia. 7. Burnet Institute, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC 3008, Australia; Department of Infectious Diseases, The Alfred and Monash University, Melbourne, VIC 3004, Australia.
Abstract
BACKGROUND: Modelling suggests that achieving the World Health Organization's elimination targets for hepatitis C virus (HCV) is possible by scaling up use of direct-acting antiviral (DAA) therapy. However, poor linkage to health services and retention in care presents a major barrier, in particular among people who inject drugs (PWID). We identify and assess the cost-effectiveness of additional health system interventions required to achieve HCV elimination targets in Australia, a setting where all people living with HCV have access to DAA therapy. METHODS: We used a dynamic HCV transmission and liver-disease progression mathematical model among current and former PWID, capturing testing, treatment and other features of the care cascade. Interventions tested were: availability of point-of-care RNA testing; increased testing of PWID; using biomarkers in place of liver stiffness measurement; and scaling up primary care treatment delivery. RESULTS: The projected treatment uptake in Australia reduced the number of people living with HCV from approximately 230,000 in 2015 to approximately 24,000 by 2030 and reduced incidence by 45%. However, the majority (74%) of remaining infections were undiagnosed and among PWID. Scaling up primary care treatment delivery and using biomarkers in place of liver stiffness measurement only reduced incidence by a further 1% but saved AU$32 million by 2030, with no change to health outcomes. Additionally replacing HCV antibody testing with point-of-care RNA testing increased healthcare cost savings to AU$62 million, increased incidence reduction to 64% and gained 11,000 quality-adjusted life years, but critically, additional screening of PWID was required to achieve HCV elimination targets. CONCLUSION: Even with unlimited and unrestricted access to HCV DAA treatment, interventions to improve the HCV cascade of care and target PWID will be required to achieve elimination targets.
BACKGROUND: Modelling suggests that achieving the World Health Organization's elimination targets for hepatitis C virus (HCV) is possible by scaling up use of direct-acting antiviral (DAA) therapy. However, poor linkage to health services and retention in care presents a major barrier, in particular among people who inject drugs (PWID). We identify and assess the cost-effectiveness of additional health system interventions required to achieve HCV elimination targets in Australia, a setting where all people living with HCV have access to DAA therapy. METHODS: We used a dynamic HCV transmission and liver-disease progression mathematical model among current and former PWID, capturing testing, treatment and other features of the care cascade. Interventions tested were: availability of point-of-care RNA testing; increased testing of PWID; using biomarkers in place of liver stiffness measurement; and scaling up primary care treatment delivery. RESULTS: The projected treatment uptake in Australia reduced the number of people living with HCV from approximately 230,000 in 2015 to approximately 24,000 by 2030 and reduced incidence by 45%. However, the majority (74%) of remaining infections were undiagnosed and among PWID. Scaling up primary care treatment delivery and using biomarkers in place of liver stiffness measurement only reduced incidence by a further 1% but saved AU$32 million by 2030, with no change to health outcomes. Additionally replacing HCV antibody testing with point-of-care RNA testing increased healthcare cost savings to AU$62 million, increased incidence reduction to 64% and gained 11,000 quality-adjusted life years, but critically, additional screening of PWID was required to achieve HCV elimination targets. CONCLUSION: Even with unlimited and unrestricted access to HCVDAA treatment, interventions to improve the HCV cascade of care and target PWID will be required to achieve elimination targets.
Authors: Claire E Kendall; Michael Fitzgerald; Jessy Donelle; Jeffrey C Kwong; Chrissi Galanakis; Rob Boyd; Curtis L Cooper Journal: Can Liver J Date: 2020-06-04
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