Cost‐effectiveness of strategies to improve HCV screening, linkage‐to‐care and treatment in remand prison settings in England

Abstract

Background A simplified cascade‐of‐care may improve screening and treatment uptake among incarcerated individuals. We assessed the cost‐effectiveness of traditional and simplified screening and treatment in a London remand prison. Methods Using empirical data from Her Majesty's Prison (HMP) Wormwood Scrubs, London, we designed a decision tree and Markov transition state model using national average data for HCV screening and treatment for the base‐case scenario. This compared two alternative strategies; (a) general prison population screening and treatment and (b) prioritising screening and treatment among people who inject drugs (PWID) combined with general prison population screening and treatment. Strategies varied the rates of screening (47%‐90%), linkage‐to‐care (60%‐86%) and treatment (21%‐85%). Cost, utility and disease transition rates were obtained from existing literature. Outcome measures were as follows: screening, treatment and disease‐related costs per admitted individual, quality‐adjusted life years (QALYs). Incremental cost‐effectiveness ratios (ICERs) were calculated for each intervention. All costs and utilities were discounted at a rate of 3.5% per annum. Both univariate and probabilistic sensitivity analyses have been conducted. Results In our cohort of 5239 incarcerated individuals with an estimated chronic HCV prevalence of 2.6%, all strategy ICER values (£3565‐10 300) fell below the national willingness to pay threshold (£30 000). Increased successful treatment (7%‐54%) was observed by an optimising cascade‐of‐care. A robust sensitivity analysis identified treatment cost of, QALY for mild liver disease and probability of completing treatment as important factors that impact the ICER value. Conclusion In our remand setting, optimising adherence to the cascade‐of‐care is cost‐effective. Where universal screening is not practical, a stratified approach focused on intensive screening and treatment of PWID also results in increased treatment uptake and is highly cost‐effective.

Implementation of HCV screening in the 1969–1989 birth‐cohort undergoing COVID‐19 vaccination

“…pregnant women, inmates). 19 , 20 , 21 , 22 Results from these studies are discordant, and peculiar aspects of the national health systems, the target population and the cost per treatment in each context should be considered in terms of low generalizability of the results. Furthermore, the cost per QALY gained in such analyses heavily depends on the prevalence of HCV infection (up to 16% in Irish inmates) and the cost of the screening programme.…”

“…In literature, examples of health economic analyses of HCV screening programmes in Europe were performed on high‐risk populations or specific target populations only (i.e. pregnant women, inmates) 19–22 . Results from these studies are discordant, and peculiar aspects of the national health systems, the target population and the cost per treatment in each context should be considered in terms of low generalizability of the results.…”

Chronic hepatitis C elimination prison initiative: HCV‐intensive test and treat, a whole prisoner population HCV test‐and‐treat program in England

“…The cost of the HITT initiative was challenging to determine as no definite costs were associated with each event. To our knowledge, no cost–benefit analyses of similar initiatives have been performed in the United Kingdom, however an analysis in a remand prison in London found that improving HCV screening and linkage to care was cost‐effective in this setting 38 . A cost‐effectiveness analysis of the HITT initiative presented here is currently being performed and will be published separately.…”

Cost-effectiveness of mass screening for Hepatitis C virus among all inmates in an Irish prison

“…The main strength of our analysis is the use of real outcome and cost data from a pilot testing and treatment intervention in a Dublin prison, although the small scale of this pilot was also a potential limitation. Importantly, we included the staff costs for a prison officer escorting a patient to appointments for treatment and the prison staff required for screening, which is not normally included [31,32]. Also, our use of a detailed HCV transmission model that incorporates data uncertainty to estimate the subsequent impact of the intervention improves the robustness of our projections.…”

“…Taiwan [34] and the UK [31]. Just considering studies using DAA treatments, all these analyses suggest that screening and treatment in prison should be cost-effective with the cost per QALY being $19,000-30,000 in the US [35][36][37] and €4,015-23,000 in Europe [31,33,38,39].…”