Intervention Packages to Reduce the Impact of HIV and HCV Infections Among People Who Inject Drugs in Eastern Europe and Central Asia: A Modeling and Cost-effectiveness Study

Abstract

BackgroundWe evaluated the effectiveness and cost-effectiveness of interventions targeting hepatitis C virus (HCV) and HIV infections among people who inject drugs (PWID) in Eastern Europe/Central Asia. We specifically considered the needle-syringe program (NSP), opioid substitution therapy (OST), HCV and HIV diagnosis, antiretroviral therapy (ART), and/or new HCV treatment (direct acting antiviral [DAA]) in Belarus, Georgia, Kazakhstan, Republic of Moldova, and Tajikistan.MethodsWe developed a deterministic dynamic compartmental model and evaluated the number of infections averted, costs, and incremental cost-effectiveness ratios (ICERs) of interventions. OST decreased frequencies of injecting by 85% and NSP needle sharing rates by 57%; ART was introduced at CD4 <350 and DAA at fibrosis stage ≥F2 at a $2370 to $23 280 cost.ResultsIncreasing NSP+OST had a high impact on transmissions (infections averted in PWID: 42% in Tajikistan to 55% in Republic of Moldova for HCV; 30% in Belarus to 61% in Kazakhstan for HIV over 20 years). Increasing NSP+OST+ART was very cost-effective in Georgia (ICER = $910/year of life saved [YLS]), and was cost-saving in Kazakhstan and Republic of Moldova. NSP+OST+ART and HIV diagnosis was very cost-effective in Tajikistan (ICER = $210/YLS). Increasing the coverage of all interventions was always the most effective strategy and was cost-effective in Belarus and Kazakhstan (ICER = $12 960 and $21 850/YLS); it became cost-effective/cost-saving in all countries when we decreased DAA costs.ConclusionIncreasing NSP+OST coverage, in addition to ART and HIV diagnosis, had a high impact on both epidemics and was very cost-effective and even cost-saving. When HCV diagnosis was improved, increased DAA averted a high number of new infections if associated with NSP+OST.

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

“…Whilst the right to health suggests that anyone infected with HCV should have access to treatment, irrespective of disease stage and drug use , some people must pay for them out of pocket in those countries where high costs and/or discrimination have led to reimbursement restrictions. Most countries that subsidize DAA therapy have restricted access in terms of who can prescribe and disease severity , despite evidence that treatment is cost‐effective when the long‐term costs of morbidity, mortality and onward transmission are included in the calculations, and provided that harm reduction is widely available . Strategies that have proven successful in bringing DAA costs down to a fraction of the list price include directly negotiating with pharmaceutical companies, licensing generics and committing to scaling up treatment in order to secure bulk discounts and achieve economies of scale .…”

Systematic review: economic evaluations of HCV screening in the direct‐acting antivirals era

“…Seventeen studies assessed the costs and effects of screening programs and antiviral treatments: seven evaluated screening in general population or subgroup of general population, five in people who inject drugs, four in high‐risk populations and three in other populations . It is to be noted here that two studies evaluated the cost‐effectiveness of HCV screening in more than one population group (general and high‐risk population, and people who inject drugs and high‐risk population).…”

“…Four studies included in this group were cost‐utility analysis and estimated the ICER as € per QALY gained, and one study was a cost‐effectiveness analysis with the ICER reported as € per life year saved (Table S3). One study was multi‐country and assessed the screening programs in five Eastern Europe countries . In all these studies, the simulated population was people who inject drugs currently or previously in charge to addition care centres (Table S3 and Data S2).…”

“…One study assessed separately the effect of HCV screening and treatment, and the effect of opioid substitution therapy and clean needle and syringe program . Another study assessed 11 possible screening strategies, treatments and harm reduction interventions for HCV and HIV infection …”

“…The results of all studies reported the screening strategies as a cost‐effectiveness option in the people who inject drugs population (Table S3). All studies concluded that screening and DAAs treatment is not generally sufficient to eliminate the HCV infection, and only the combination with additional interventions, such as opioid substitution therapy, clean needle and syringe program and education, has the potential to be successful in the people who inject drugs population . Screening combined with education and care coordination for all HCV infected subjects was the most cost‐effectiveness strategy compared to no intervention, program based on only screening or program based on screening plus education .…”