Is the universal population Hepatitis C virus screening a cost-effective strategy? A systematic review of the economic evidence.

OBJECTIVE: Efficient strategies are needed in order to achieve the objective of the WHO of eradicating Hepatitis C virus (HCV). Hepatitis C infection can be eliminated by a combination of direct acting antiviral (DAA). The problem is that many individuals remain undiagnosed. The objective is to conduct a systematic review of the evidence on economic evaluations that analyze the screening of HCV followed by treatment with DAAs.
METHODS: Eleven databases were performed in a 2015-2018-systematic review. Inclusion criteria were economic evaluations that included incremental cost-effectiveness ratio (ICER) in terms of cost per life year gained or quality-adjusted life year.
RESULTS: A total of 843 references were screened. Sixteen papers/posters meet the inclusion criteria. Ten of them included a general population screening. Other populations included were baby-boomer, people who inject drugs, prisoners or immigrants. Comparator was "standard of care", other high-risk populations or no-screening. Most of the studies are based on Markov model simulations and they mostly adopted a healthcare payer´s perspective. ICER for general population screening plus treatment versus high-risk populations or versus routinely performed screening showed to be below the accepted willingness to pay thresholds in most studies and therefore screening plus DAAs strategy is highly cost-effective.
CONCLUSIONS: This systematic review shows that screening programmes followed by DAAs treatment is cost-effective not only for high risk population but for general population too. Because today HCV can be easily cured and its long-term consequences avoided, a universal HCV screening plus DAAs therapies should be the recommended strategy to achieve the WHO objectives for HCV eradication by 2030. ©The Author 2020. Published by Sociedad Española de Quimioterapia. This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).

INTRODUCTION

World Health Organization (WHO) has recommended elimination of hepatitis C virus (HCV) as a public health threat by 2030. It has been estimated that 71 million persons were living with chronic HCV in 2015 [1] and 1.75 million new HCV infections occurred in that year (global incidence rate: 23.7 per 100,000) [1, 2]. Main challenge to HCV elimination is the fact that only 20% of the persons living with HCV had been already diagnosed, and –from themonly 7% started treatment [1]. Population over 40 years old who once suffered certain medical interventions with low level of sterilization would remain infected and asymptomatic and represent a clear vector for HCV transmission and a risk for their future clinical decompensation. Moreover, transmission is still active in certain populations such as people who inject drugs (PWID), inmates in prisons, carriers of illegal tattoos or perinatal transmission or individuals with several sexual intercourses.

Chronic HCV infection may lead to severe and progressive systemic disease. Although chronic HCV infection is often asymptomatic, the long-term consequences are well known. WHO considered 700,000 people die each year from chronic hepatitis C related-liver disease. Chronic Hepatitis C infection is considered the leading cause of cirrhosis, liver cancer and liver transplant [1]. The risk of cirrhosis ranges from 15% to 30% after 20 years of infection with HCV. Each year 1–3% of persons with cirrhosis progress to hepatocellular carcinoma [1]. Not only liver diseases cause an extensive clinical morbidity and large economic costs, in addition, also some extrahepatic diseases, like Diabetes Mellitus, cryoglobulinemia, renal diseases, depression or chronic fatigue, also would limit the quality of life, work productivity and increases morbidity [1-10].

A major barrier to HCV eradication still results from the fact that a substantial proportion of patients with chronic HCV infection are unaware of their infection [3]. This landscape makes it crucial to consider the implementation of screening programmes.

Previously, certain economic evaluations attempted to shed light on the efficiency of implement screening programmes at diverse target population. These evaluations were conducted before direct-acting-antiviral drugs (DAAs), screening and treatment strategies when interferon/ribavirin were not a real universal treatment due to the severe tolerability issues, low efficacy and administration pathway limitations. Initially international guidelines recommended regular screening at high-risk populations like PWID or several birth cohorts (BC). A short course of DAAs have an excellent safety profile and an effectiveness up to 95%, making possible the cure and limiting the possibility of transmission [1, 3, 30]. Therefore, screening programmes may have a broad vision and would point to general population.

In fact, WHO proposes to reduce HCV around the world and control the epidemic for 2030 [1]. In 2016, a WHO global strategy on viral hepatitis was launched, with a stated goal to eliminate hepatitis C as public health threat, and bold targets for reduction in incidence and mortality by 2030: The goal of 90% reduction in new chronic infections and a 65% reduction in mortality compared to 2015 levels, highlight objectives from WHO can only be achieve setting up screening programmes around the world and covering, not only high-risk populations, but general population if possible. Population target, treatment access and cost effectiveness of the strategies are today hot topics for physicians, payers and Organizations [2].

In the current era of increasing health costs, assessment of the potential benefits of any new strategy must take into account cost-effectiveness compared to previous strategies, that is, combining long-term effects on clinical outcomes and total healthcare costs. At this scenario, pharmacoeconomic models provide the possibility to make changes in the assumptions about the design or population, they can estimate different profile populations and can be adapted at country level. Costs of the new HCV generation drugs are currently decreasing in some countries and will make it possible to treat more patients with the same budget.

The aim of this systematic review was to perform a focused review of the literature to identify relevant studies about economic evaluations for HCV screening plus treatment including DAAs strategies of the new treatment era (2015-2018).

METHODS

A systematic review was completed. Eleven databases were searched from February 2015 to April 2018 (Web of Science, MEDLINE, EMBASE, ProQuest, Premier-EBSCO, Springer Link, Google Scholar, Science Direct, Cochrane, Scopus and Open Access). Search strategies were based on the terms “HCV OR Hepatitis C” AND “screening” and “cost analysis” into the frame time of 2015-2018. Every search at the different engines were stored and filed. In addition, a manual search was carried out in abstract-book of international hepatology congresses in April 2018 to complete and update the review. Double checking by authors name were done at Medline at December 2018 in order to add final papers in case of any poster from congresses previously included were published.

Studies to be included in the systematic review need to meet the following criteria: (i) Screening plus treatment with DAAs, therapies without interferon studies. (ii) Full economic evaluation that contained incremental cost-effectiveness/utility ratio (ICER, ICUR) in terms of cost per life year gained or quality-adjusted life year (QALY). (iii) Written in English language. Studies were excluded if (i) They were incomplete abstracts or commentaries, (ii) Partial economic evaluations. (iii) Pure screening strategies studies focus on diagnostic methodology or epidemiology (iv) HCV treatment studies, not focus on screening, (v) Models built up based on previous interferon combinations.

For quality assessment, to evaluate the quality of the economic evaluations included we adopted the Dr Stawowczyk´s methodology to evaluate the quality of the publications according to the CHEERS key points, considering “1” if they are explicit or “cero” in case this aspect does not appear properly at the paper [5, 6].

Data were systematically extracted. Studies were primarily grouped by year and author´s alphabetical order and secondly analysed according to the population profile screened: PWID, prison population, birth cohorts (BC), general population (GP), etc. We performed a file from each study and summarised all of them in evidence tables. Data extraction was subsequently reviewed and discussed by a second member of the team.

RESULTS

During the initial search, a total of 843 potential abstracts were screened. In addition, after the EASL Conference (Paris, April 2018), twenty-five abstracts were carefully reviewed. Data duplication were removed. Some studies were discarded based on the tittle and abstract and 58 publications were fully reviewed. A total of 16 studies were ultimately identified and selected based on the inclusion/ exclusion criteria [7-23] (figure 1). Most of them were high-quality papers and abstracts according to the CHEERS´s 24-item review checklist (table 1). Main pharmacoeconomic aspects were reviewed through this checklist. All of them showed measurement of effectiveness and incremental costs and outcomes, reported costs, QALYs and ICER. Eleven out of 16 showed >90% agreement with the checklist item. Two conference abstracts initially selected were also available in full article format published before the end of 2018 and considered in both formats [12, 13, 18, 19].

Figure 1

Flow diagram of included studies. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram.

DAAs: Direct Acting Antivirals: EE, Economic Evaluations

Table 1

CHEERS statement checklist (ISPOR). Quality assessment.

CHEERS Item no.	USA					France		Korea		Spain		UK		Australia	Canada	India
	He2016[7]	Linthicum2016[8]	Rattay2017[9]	Younossi2017[10]	Barbosa2018[11]	Deuffic-Burban 2016 [12,13]	Ethgen2016[14]	Kim DY2017[15]	Kim KA2018[16]	Buti2018[18,19]	Cuadrado2018[20]	Martin2016[21]	Selvapatt2016[22]	Scott2017[23]	Wrong2017[24]	Chaillon2017[25]
01 Title	0	0	1	0	1	1	0	1	1	1	1	1	1	1	1	1
02 Abstract	1	1	1	1	1	1	1	1	0	1	0	1	1	1	1	0
03 Background and objectives	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
04 Target population and subgroups	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
05 Setting and location	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
06 Study Perspective	1	1	1	1	1	1	1	1	1	1	0	0	1	0	1	1
07 Comparators	1	1	1	1	1	1	1	1	1	1	0	1	1	1	1	1
08 Time horizon	1	1	0	1	1	1	1	1	1	1	0	1	1	1	1	1
09 Discount rate	1	1	1	1	1	0	1	1	0	1	0	1	1	1	1	1
10 Choice of health outcomes	1	1	1	1	1	1	1	1	1	1	0	1	1	1	1	1
11 Measurement of effectiveness	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
12 Measurement and valuation of preference-based outcomes	1	1	1	1	0	1	1	1	1	1	1	1	1	1	1	1
13 Estimating resources and costs	1	1	1	1	0	1	1	1	1	1	1	1	1	1	1	1
14 Currency, price date, conversion	1	1	0	1	0	1	1	1	1	1	1	1	1	0	1	1
15 Choice of model	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
16 Model assumptions	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
17 Analytic methods	1	1	1	1	0	1	1	1	1	1	1	1	1	1	1	1
18 Study parameters	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
19 Incremental costs and outcomes	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
20 Characterising uncertainty	1	1	1	1	1	1	1	1	1	1	0	1	1	1	1	1
21 Characterising heterogeneity	1	1	1	1	0	1	1	1	1	1	0	1	1	1	1	1
22 Discussion	1	1	1	1	0	1	1	1	1	1	0	1	1	1	1	0
23 Source of funding	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1	1
24 Conflicts of interest	1	1	1	0	1	1	1	1	1	1	0	0	1	1	1	0
Total	23	23	22	22	18	23	23	24	22	24	14	22	24	23	24	21
	98%	98%	92%	92%	75%	98%	98%	100%	92%	100%	58%	92%	100%	98%	100%	88%

CHEERS: Consolidated Health Economic Evaluation Reporting Standards [5] and Stawowczyk´s quality assessment of included studies with ISPOR CHEERS statement checklist [6]; NA: not applicable, 0: not satisfied; 1: satisfied.

The population studied was mainly general population (10 studies). At table 2 there has been summarized the study groups and the comparators [7-25]. Although population profiles are important to understand the results, also the country of origin, the local prevalence and willingness-to-pay are key points. At table 3 main pharmacoeconomic variables have been compilated. Discrete-time Markov model (+/decision tree) were used in all of them to modelled HCV progression and transmission and to analyse the costs and benefits of investment in screening and treatment. Every European and Asian studies used the third-party payor perspective, most of them including a 3% discount rate for costs and outcomes [10-13, 15, 16, 20, 22, 23]. Some USA studies used a societal perspective including but not limited to direct costs [7-9]. Costs were reported in incremental costs per patient or in total program costs. The benefit in QALYs moved from 0.001 to 21,000. ICER varied from AU$47 to US$ 59,589 at high-risk populations and from cost-saving to CAD$ 50,490 for general population. Willingness-to-pay varies from US$ 1,580 to CAD$ 120,000. Studies concluded different target populations are showed to be below of accepted willingness-to-pay thresholds in the reference country (table 3). Relevantly, Younossi et al. showed general population screening to be a dominant strategy relative to birth cohort and relative to high-risk screening cohort and ICERs moved between USD $15,968 and $8,660 [10]. In addition, eight of the studies described how they could prevent a great number of liver-related deaths, liver transplantations, cases of hepatocellular carcinoma, and cases of decompensated cirrhosis in the next years, according to the study horizon [7, 13, 14-16, 17, 19-22]. He et al. considered that, compared with no-screening, HCV screening in prisons could prevent 4,200 to 11,700 liver-related deaths, 300 to 900 liver transplantations, 3,000 to 8,600 cases of hepatocellular carcinoma, and 2,600 to 7,300 cases of decompensated cirrhosis in the next 30 years, most of the episodes outside of prison [7]. At South Korea´s general population, Kim et al. estimated to avoid around 1,000 decompensated cirrhosis events and 3,000 hepatocellular carcinomas over five-year time horizon, with the largest reductions estimated in those aged 40-49 years old at the time to diagnose and treat. A second Korean study estimated that, under a lifetime perspective, they can prevent death by 32 per 100,000 screened people [15, 16]. In addition, Buti et al. estimated decompensating hepatic disease, transplant and death related would be reduced more than 50% [17]. Nevertheless, the authors consider their model would underestimates the true clinical benefits because they did not consider improvements at the extrahepatic manifestations.

Table 2

Summary of studies: population and comparators

Country	Study,Author, year [reference]	Population	Comparator	HCV estimated Prevalence
USA	He, 2016 [7]	Prisoners: Risk-Based Screening	No-screening	n/a
		All incoming inmates for up to 1 year
		All incoming inmates-5 years
		All incoming inmates-10 years
	Linthicum, 2016 [8]	GP born before 1992 (42% Baby boomers)	Current screening	n/a
		PWID
		MSM-HIV
	Rattay, 2017 [9]	GP at Primary care standard	Current practice	1,09%
		GP at Primary care, ECHO project
	Younossi, 2017 [10]	GP	BC	n/a
		BC (born between 1945-1965)	HR
		HR: current or past PWID
	Barbosa, 2018 [11]	PWID: scale up patients on medication assisted treatment and syringe service programs	Current Practice	n/a
		PWID: Scale up + 90% annual screening
France	Deuffic-Burban, 2016 [12, 13]	GP 18-60 years old	Current Screening	n/a
		GP 40-80 years old
		GP
	Ethgen, 2016 [14]	BC born 1945-1965 with Low Risk of infection	Among 5 treatment strategies(no antiviral therapy; IFN + ribavirin + protease inhibitor for fibrosis stages F2–F4,IFN-based DAAs for stages F2–F4, IFN-free DAAs for stages F2–F4, and IFN-free DAAs for stages F0–F4)	0.53%
		BC born 1945-1965 with Intermediate Risk of infection
		BC born 1945-1965 with High Risk of infection
South Korea	Kim DY, 2017 [15]	GP (Age 40±49 years)	No-Screening	0.78%
		GP (Age 50±59 years)
		GP (Age 60±69 years)
	Kim KA, 2018 [16]	GP (Age 40±65 years)	No-Screening
		GP (Age 40±49 years)		0.00038
		GP (Age 50±59 years)		0.0061
		GP (Age 60±65 years)		0.0106
Spain	Buti, 2018 [18, 19]	GP born between 1938-1997 (20-79 years)	General population highest anti-HCV prevalence born between 1938-1967	0.5-1.5%
	Cuadrado, 2018 [20]	GP at nine different age cohorts	Natural History Scenario	1.2%
UK	Martin, 2016 [21]	In prison: 8-week to 12-week IFN-free DAAs	In Prison: Status Quo	n/a
		In prison: treatment scale-up for PWID
	Selvapatt, 2016 [22]	PWID: Screening and treatment as observed within the study populations (22 triple therapy, 7 DAAs)	No-Screening, No-Treatment	n/a
		PWID: Screening and treatment, assuming all patients treated with hypothetical DAA therapy and SVR 95%
Australia	Scott, 2017 [23]	PWID: Scale up primary care	Current Standard of Care but with DAAs available for everyone	Annual incidence rate11.9%
		PWID Scale up primary care + APRI
		PWID: Scale up primary care + APRI + annual testing of PWID on OST
		PWID: Scale up primary care + APRI + point of care RNA
		PWID: all heath system interventions
Canada	Wong, 2017 [24]	GP	No-Screening
		immigrant populations with high prevalence
		BC people aged 25–64 years
		BC aged 45–64 years of age
INDIA	Chaillon, 2017 [25]	GP at HCV prevalence 0.5%	No-Screening	0.5%
		GP at HCV prevalence 1%		1%
		GP at HCV prevalence 1.5%		1.5%

GP: General Population; PWID: People Who Inject Drugs; MSM-HIV : HIV-Men have sex with men; BC: Birth Cohort Population; HR: High Risk Population; APRI: AST to Platelet Ratio Index; OST: Opioids Substitution Therapy; DAAs: Direct Acting Antivirals HCV; IFN-free: Interferon-free ; DAAs: HCV Direct Acting Antivirals; RNA: Ribonucleic Acid; n/a: Data not available at the paper/poster

Table 3

Summary of cost-effectiveness results

StudyAuthor, year(Country) [reference]	Population	Model	Perspective	Horizon &Discount	ICER	WTP
Deuffic-Burban, 2016 (France) [12, 13]	GP (18-80 yr) vs current-screening	CUA, Decision tree and Markov model	Societal	Lifetime, 4%	$27,600 – 46,300	n/a
Ethgen, 2016(France) [14]	BC born 1945-1965 with different Risk of infection among diverse treatment approaches	CUA/CEA, Markov model	French Health Care System	20 years, 4%	$22,986 to $59,589	n/a
He, 2016(USA) [7]	Prisoners vs no-screening	CUA, microsimulationmodel	Societal	30 years, 3%	$19,600 29,200	$50,000
Linthicum, 2016 (USA) [8]	GP (born before 1992) vs current-screening	CUA, Markov model	Societal	20 years, 3%	-$6,747	n/a
Martin, 2106(UK) [21]	Prisoners vs status quo	CUA, Dinamic transmision model	UK National Health Service	100 years, n/a	£15,090 £6,180	£20,000 £30,000
Selvapatt, 2016 (UK) [22]	PWID vs no-screening	CUA, Markov model	Payer	100 years Healthcare System, 3.5%	£1,029	£20,000 £30,000
Chaillon, 2017 (India) [25]	GP vs non-screening	CUA, Markov model	Heathcare Provider	Lifetime, 3%	$1,471 – 2,942	$1,580
Kim, 2017(South Korea) [15]	GP (Age 40±70) vs no-screening	CUA, Markov model	Public Health	5 years, 5%	$ 5,714 8,889	$ 27,512
Rattay, 2017 (USA) [9]	GP vs current-screening	CUA, Decision tree	Societal	Lifetime, 3%	$10,351	$100,000
Scott, 2017(Australia) [23]	PWID vs current standard	CUA, Dynamic compartimental model	Healthcare System	2016-2030, 0-3%	AU$ 47	n/a
Wong, 2017 (Canada) [24]	GP (15-79 yr) vs non-screening	CUA, State transitionmodel	Third-Party Payer	Lifetime, 5%	C$31,468 – 50,490	C$50,000 – 120,000
Younossi, 2017 (USA) [10]	GP (>20 yr) vs BC (1945-1967) and GP (>20 yr) vs HR	CUA, State transitionmodel	Third-Party payer	Lifetime, 3%	$15,968 – 8,660	$50,000
Barbosa, 2018(USA) [11]	PWID scale up vs current practice	CUA, Two dinamic compratmental models	Third-Party payer	10 years, 3%	$ 6,767 11,618	$ 50,000
Buti, 2018 (Spain) [18, 19]	GP (20-79 yr) vs HR and GP (20-79 yr) vs the highest prevalence	CUA, Decision treeand Markov model	National Health System	Lifetime, 3%	$226 – 8,914	$22,000 – 30,000
Cuadrado, 2018 (Spain) [20]	GP (20-74 yr) vs standard	CEA Epidemiological andMarkov model	Third-Party Payer	Lifetime, n/a	-$336 – 3,904	n/a
Kim KA, 2018(Korea) [16]	GP (Age 40±70) vs no-screening	CUA, Markov model	Healthcare System	Lifetime, 5%	$7,218 – 7,787	$27,205

CUA: Cost-utility analysis; CEA: Cost-effectiviness analysis; n/a: not available at the paper/poster; GP: General Population; BC: Birth Cohort Population; HR: High Risk Population; PWID: people who inject drugs; ICER: incremental cost-effectiveness ratio; WTP: willingness to pay; yr: years

LIMITATIONS

This review has several limitations. Although an exhaustive search was performed, it is possible that not all the relevant studies were included. Only papers in English were included. The strong subject diversity at the methodology between studies and the diversity of country-characteristics make it difficult to stablish comparations and analysis. Some studies have not been yet published at paper format, and there is only poster information available; this has an impact on the CHEERS checklist punctuation. Lack of information would allow authors to use values of utilities from models that were obtained from interferon studies performed before 2015.

DISCUSSION

WHO proposes to eradicate viral hepatitis as a public health threat by 2030. In order to fulfil this objective, HCV screening programmes seems to be a leverage point. The evidence to propose a regular screening to a wide population is low, and recommendations are sometimes conditional. If eradication of chronic HCV infection as a public health threat requires diagnosing 90% of those infected and treating 80% of those diagnosed, new campaigns to introduce and reinforce testing and treatment should be implemented in order to address this important gap [1].

Barriers imposed by previous treatments (i.e., sub-optimal efficacy, inadequate tolerability, longer duration of treatment) are no longer applicable. Screening programmes would make possible the strategies to “one-time-screening” and to “test and treat”. Thanks to the DAAs regimens, treatment after screening can be simpler, shorter, safer and better tolerated, so rejection from HCV infected patients would be expected to be very low, while cure rate is expected in almost every patient who completes treatment.

Good quality screening systematic reviews were previously published in the past [26-31], analysed interferon-based therapies with a suboptimal tolerability profile and lower efficacy. The scenario have changed with the current DAAs treatments that allow to increase the number and characteristics of HCV infected subjects that can receive therapy. According to that, there are needed of cost-effectiveness data including general population evaluation arms. For this reason, we performed the current systematic review, traying to put in perspective the screening evidences at the current DAAs treatment era. Cost-effectiveness ratio (ICER) is highly favourable at most of the comparations, being screening plus DDAs treatment a cost-effective strategy not only for prisoners, inmates who left the prison and PWID, but also cost-effective for selected birth cohort populations and general population. Most of the model results are considered to be below the willingness-to-pay threshold [7-25]. Studies considered some populations at different regions. This broad representation means that the topic interests to diverse economic and health system settings. Although the implementation of the strategy implies an increase of current budget because cost increases for the first years, it seems that screening campaigns would break even in less than ten years [8]. From a clinical perspective, long term clinical complications particularly hepatocellular carcinoma will reduce but not abolish in the next years and savings have to be analysed in future studies that also include the impact of extra-hepatic disease, tiredness, mood disturbances (like anxiety, and depression), health related quality of life (HRQL) and work productivity impact.

The cost of the DAA drugs has been a “hot” topic and it impacted to the current cost-effectiveness studies. Fortunately, prices have dropped around the world and it is estimated that they will continue to decrease even further. Most models include a sensitivity analysis that incorporates a 20% decrease in DAA cost. Reducing costs at the sensitivity analysis means conclusions of the models are even more cost-effective. This scenario would be the real access situation for the next years, providing the possibility to screen and treat more patients with the same budget. Other key factors that showed more impact at the analysed studies were the local prevalence, the age at diagnosis, the time between test and treatment and the fibrosis level. These factors are aligned with the current WHO recommendations that suggest not delay the HCV treatment after positive screening.

The access to HCV testing and therapy is still suboptimal in many countries due to the disease is asymptomatic for many years. At this point, the one-step testing shows a great initiative that support an easier and shorter screening methodology, losing less patients in the process. In addition, several studies promote strategies to involve more in deep to primary care services at the HCV management [9, 23], reducing the number of patients lost and promoting early treatment under a “test and treat initiative”. It is crucial that at country level this pathway and sensitivity would be designed and implemented under this new scenario and possibilities. Several success examples, like the Scottish initiative (2006), Germany (2013), Italy and Spain (2015) have increased the fight against HCV infection [32]. A recent example would be the Spanish National Plan for HCV which achieve treatment to more than 117,500 patients in around three years, with a shared effort between payors, pharmaceutical companies and physicians [33]. They are now focused on increasing one-time diagnostic process among asymptomatic individuals in order to reduce the number of silent infections, increasing new diagnosis while avoiding losing patients in the process. These local collaborative initiatives may constitute the framework to design a strategy for the future. This strategy would need to be supported by local epidemiological and cost-effectiveness studies taking into account their own resources.

Like other infectious diseases, preventive medicine allows society to get ahead the disease, preventing its evolution and avoiding suffering, death and costs. From the moment that effective and well tolerated therapies are available, HCV screening and treatment cost-effectiveness requires to be evaluated as a successful strategy at the general population level. Although more evidence is needed at each country level, the current data suggest that screening recommendations for the general population should be included on international guidelines as a major public health strategy.

CONCLUSION

An HCV strategy of “test and treat” is cost-effective for screening of HCV high risk population and also for the general population. Because currently HCV can be easily cured, and the majority of long-term consequences can be avoided, a universal HCV screening plus DAAs treatment should be the recommended strategy to achieve the WHO objectives of HCV eradication by 2030.