IMPORTANCE Testing for and treating latent tuberculosis infection (LTBI) is among the main strategies to achieve TB elimination in the United States. The best approach to testing among non-US born residents, particularly those with comorbid conditions, is uncertain.OBJECTIVE To estimate health outcomes, costs, and cost-effectiveness of LTBI testing and treatment among non-US born residents with and without medical comorbidities. DESIGN, SETTING, AND PARTICIPANTS Decision analytic tree and Markov cohort simulation model among non-US born residents with no comorbidities, with diabetes, with HIV infection, or with end-stage renal disease (ESRD) using a health care sector perspective with 3% annual discounting. Strategies compared included no testing, tuberculin skin test (TST), interferon gamma release assay (IGRA), confirm positive (initial TST, IGRA only for TST-positive results; both tests positive indicates LTBI), and confirm negative (initial IGRA, then TST for IGRA-negative; any test positive indicates LTBI). All strategies were coupled to treatment with 3 months of self-administered rifapentine and isoniazid. MAIN OUTCOMES AND MEASURESNumber needed to test and treat to prevent 1 case of TB reactivation, discounted quality-adjusted life-years (QALYs), discounted lifetime medical costs, and incremental cost-effectiveness ratios (ICERs).RESULTS Improving health outcomes increased costs, with choice of test dependent on willingness to pay. Strategies ranked by ascending costs and benefits: no testing, confirm positive, TST, IGRA, and confirm negative. The ICERs varied by non-US born patient risk group: patients with no comorbidities, IGRA

In addition to risk-based testing, one-time HCV testing of persons 18 and older appears to be cost-effective, leads to improved clinical outcomes and identifies more persons with HCV than the current birth cohort recommendations. These findings could be considered for future recommendation revisions.

Routine rapid HCV testing among 15- to 30-year-olds may be cost-effective when the prevalence of PWID is >0.59%.

Objective-To estimate the clinical effects and cost-effectiveness of universal prenatal hepatitis C screening, and to calculate potential life expectancy, quality of life, and health care costs associated with universal prenatal hepatitis C screening and linkage to treatment. Methods-Using a stochastic individual-level microsimulation model, we simulated the lifetimes of 250 million pregnant women matched at baseline with the U.S. childbearing population on age, injection drug use behaviors, and hepatitis C virus (HCV) infection status. Modeled outcomes included hepatitis C diagnosis, treatment and cure, lifetime health care costs, quality-adjusted life years (QALY) and incremental cost-effectiveness ratios (ICERs) comparing universal prenatal hepatitis C screening to current practice. We modeled whether infants exposed to maternal hepatitis C virus (HCV) at birth were identified as such. Results-Hepatitis C virus-infected pregnant women lived 1.21 years longer and had 16% lower HCV-attributable mortality with universal prenatal hepatitis C screening, which had an ICER of $41,000 per QALY gained compared to current practice. Incremental cost-effectiveness ratios remained below $100,000 per QALY gained in most sensitivity analyses; notable exceptions included ICERs above $100,000 when assuming mean time to cirrhosis of 70 years, a cost greater than $500,000 per false positive diagnosis, or population HCV infection prevalence below 0.16%. Universal prenatal hepatitis C screening increased identification of infants exposed to HCV at birth from 44% to 92%. Conclusions-In our model, universal prenatal hepatitis C screening improves health outcomes in HCV-infected women, improves identification of HCV exposure in infants born at risk, and is cost-effective. PRÉCIS Universal testing for hepatitis C in pregnancy is cost effective and would increase average life expectancy by 1.21 years for infected women.

Background Hepatitis C virus (HCV) testing and treatment uptake in prisons remains low. We aimed to estimate clinical outcomes, cost-effectiveness (CE), and budgetary impact (BI) of HCV testing and treatment in United States (US) prisons or linkage to care at release. Methods We used individual-based simulation modeling with healthcare and Department of Corrections (DOC) perspectives for CE and BI analyses, respectively. We simulated a US prison cohort at entry using published data and Washington State DOC individual-level data. We considered permutations of testing (risk factor based, routine at entry or at release, no testing), treatment (if liver fibrosis stage ≥F3, for all HCV infected or no treatment), and linkage to care (at release or no linkage). Outcomes included quality-adjusted life-years (QALY); cases identified, treated, and cured; cirrhosis cases avoided; incremental cost-effectiveness ratios; DOC costs (2016 US dollars); and BI (healthcare cost/prison entrant) to generalize to other states. Results Compared to “no testing, no treatment, and no linkage to care,” the “test all, treat all, and linkage to care at release” model increased the lifetime sustained virologic response by 23%, reduced cirrhosis cases by 54% at a DOC annual additional cost of $1440 per prison entrant, and would be cost-effective. At current drug prices, targeted testing and liver fibrosis–based treatment provided worse outcomes at higher cost or worse outcomes at higher cost per QALY gained. In sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs. Conclusions Although costly, widespread testing and treatment in prisons is considered to be of good value at current drug prices.

In 2012 the Centers for Disease Control and Prevention recommended routine testing for hepatitis C for people born in the period 1945–65. Until now, the recommendation’s impact on hepatitis C screening rates in the United States has not been fully understood. We used an interrupted time series with comparison group design to analyze hepatitis C screening rates in the period 2010–14 among 2.8 million commercially insured adults in the MarketScan database. Hepatitis C screening rates increased yearly between 2010 and 2014, from 1.65 to 2.59 per 100 person-years. A 49 percent increase in screening rates among people born during 1945–65 followed the release of the recommendation, but no such increase was observed among adults born after 1965. The effect among the target population was sustained, and by twenty-four months after the recommendation’s release, screening rates had increased 106 percent. We conclude that the hepatitis C testing policy change resulted in significantly increased testing among the target population and may have decreased the magnitude of the hepatitis C epidemic.

Introduction: There is no widely accepted testing approach for hepatitis C virus infection in correctional settings, and many U.S. prisons do not provide routine testing. The aim of this study was to determine the most effective hepatitis C virus testing strategy in one U.S. state prison and describe the population with reactive testing. Methods: A retrospective analysis was performed using individuals entering the Washington State prison system, which routinely offers hepatitis C virus testing, to compare routine opt-out to current recommendations for risk-based and one-time testing for individuals born between 1945 and 1965. Additionally, liver fibrosis stage was characterized using aspartate aminotransferase to platelet ratio index and Fibrosis-4. Analyses were conducted in 2017. Results: Between 2012 and 2016, a total of 24,567 (83%) individuals were tested for the hepatitis C virus antibody and 4,921 (20%) were reactive (test was positive). There were 2,403 (49%) that had hepatitis C virus RNA testing with 1,727 (72%) showing chronic infection. Reactive antibody was more prevalent in individuals born between 1945 and 1965 compared with other years (44% vs 17%); however, most cases (72%) were outside of this cohort. Up to 35% of positive reactive tests would be missed with testing targeted by birth cohort and risk behavior. Of chronically infected individuals, 23% had at least moderate liver fibrosis. Conclusions: Targeted testing in the Washington State prison system missed a substantial proportion of hepatitis C virus cases; of those with reactive testing, a sizeable proportion of people had at least moderate liver disease placing them at risk for complications. Routine testing at entry should be considered by U.S. state prisons.

I n this issue of AJKD, Campbell et al 1 used decisionanalytic modeling to investigate the health benefits and associated costs (or cost-effectiveness) of routinely screening for latent tuberculosis (TB) infection (LTBI)