Hepatitis C virus elimination in Indonesia: Epidemiological, cost and cost‐effectiveness modelling to advance advocacy and strategic planning

Abstract

Backgrounds & Aims:In Indonesia 1.9 million people are chronically infected with hepatitis C virus (HCV), but a national strategic plan for elimination has not yet been developed, despite the availability of low-cost treatments which could save many lives. We used epidemiological and cost modelling to estimate targets and resource requirements of a national elimination program and explore the potential impact and cost-effectiveness. Methods: To model the HCV epidemic, we used a dynamic model, parameterised with Indonesia-specific data, accounting for disease progression, injecting drug use and demographics. Future scale-up scenarios were designed for 2018-2050 to capture possible policy choices. Costs of an initial 5-year national strategy and of long-term elimination were estimated for the most feasible scenario, as agreed with government and local partners. Cost savings from reduced drug and diagnostics prices were also estimated. The cost-effectiveness of baseline predictions and those with drug price reductions were compared to the no treatment scenario. Results: Elimination by 2045, considered the most feasible path to scale-up, would prevent 739 000 new infections and avert 158 000 HCV-related deaths. The costs would be $5.6 billion (USD) using baseline prices but could fall to $2.7 billion if price reductions for HCV drugs and diagnostics are secured. With these price reductions, the incremental cost-effectiveness ratio for a 2045 elimination program would be cost-effective at $300 (USD) per year of life saved vs the no treatment scenario. Conclusions:This study has underpinned advocacy efforts to secure Indonesian government commitment to HCV elimination, and provides further inputs for HCV strategic planning efforts. | 287TRICKEY ET al. | Scenario designTo understand the range of possible policy responses, we modelled treatment scale-up scenarios of varying elimination timeframes and scale-up intensity. The WHO definition for elimination is an 80% reduction in HCV incidence and a 65% reduction in HCV-related mortality from 2015 levels.

Diagnostic Performance of APRI and FIB-4 for Confirming Cirrhosis in Indonesian HIV/HCV Co-infected Patients

“…Based on previous report from Indonesia, an average cost before starting HCV therapy was USD 191, including USD 74 for TE examination. [2] This high cost could delay treatment initiation for many patients though government provide the drugs. As the majority of HCV infection in Indonesia were driven by unsafe opiate injection around year 2000, we could predict that many untreated HCV-HIV co-infected patients have already in their cirrhosis stage.…”

“…[19,20] Since the Indonesian government planned to expand free DAA program for HCV, the result our study could be implemented in many places, as WHO also recommends to use APRI and FIB-4 in resourceconstraint countries. [2,14] This study has several limitations. First, the number of end-stage liver diseases were small.…”

“…[4] In 2017, Indonesian government started free direct acting antiviral (DAA) program for HCV, mainly sofosbuvir and daclatasvir combination. [2,5] This 12 weeks combination for non-cirrhotic patients and 24 weeks for cirrhoticpatients shown similar success rate for both HIV/HCV co-infected patients and HCV mono-infected patients. [6] Despite these facts, there are still many barriers to start HCV treatment, especially in defining liver fibrosis phase.…”

“…[1] In Indonesia, HCV infection prevalence is estimated at 1%, of which 90% comes from intravenous drug user. [2] World Health Organization (WHO) recently released targets for HCV elimination by 2030, targeting 80% HCV-infected patients being treated. [1] A large gap between HCV-diagnosed patients and HCV-treated patients still exist to achieve this global target since only around 10% of HCV-infected patients in South East Asia have been treated.…”

Diagnostic Performance of APRI and FIB-4 for Confirming Cirrhosis in Indonesian HIV/HCV Co-infected Patients

“…[1] In Indonesia, HCV infection prevalence is estimated at 1%, of which 90% comes from intravenous drug user. [2] World Health Organization (WHO) recently released targets for HCV elimination by 2030, targeting 80% HCV-infected patients being treated. [1] A large gap between HCV-diagnosed patients and HCV-treated patients still exist to achieve this global target since only around 10% of HCVinfected patients in South East Asia have been treated.…”