Cost-effectiveness of Scaling Up HCV Treatment, Medication-Assisted Treatment, and Syringe Service Programs for People Who Inject Drugs in San Francisco and Rural Kentucky

Background: The current epidemic of opioid abuse in the United States has led to high prevalence of Hepatitis C virus (HCV) amongst people who inject drugs (PWID). The high treatment cost ($26, 400 for the cheapest pan-genotype drug approved so far), and the large number needing treatment, raise questions of affordability for scaling up treatment rates. Combining medication-assisted treatment (MAT) and syringe service programs (SSP) with HCV treatment can impact both incidence and prevalence of HCV infection, and may be more effective in reducing the transmission of HCV amongst PWID than any one of those strategies alone.

Objective: Estimate the cost-effectiveness of treating HCV infections in PWID in a rural and urban U.S. setting (Perry County [PC], Kentucky and San Francisco [SF]).

Methods: We used setting-specific data to calibrate two dynamic models of HCV transmission and progression of the PWID population in urban SF and rural PC. SF has an older stable population of PWID (30,000 in 2007) who primarily inject heroin with relatively high coverage of SSP (84%) and low coverage of MAT (12%); whereas PC’s PWID population (700 in 2009) is young and increasing, primarily injects prescription opioids, and has no SSP and limited MAT (5%). We modeled three intervention scenarios: Baseline (BL) Existing SSP and MAT coverage with HCV screening and treatment with direct-acting anti-viral (DAAs) for ex-injectors only as per standard of care; Intervention 1 (I1) Scale-up of SSP and MAT without changes to treatment; Intervention 2 (I2) Scale-up as I1 combined with HCV screening and treatment for current PWID. A health care perspective was used and included costs of MAT, SSP, screening and diagnosis of HCV, HCV treatment and monitoring, and HCV-related complications. Health outcomes included quality-adjusted life years (QALYs) and number of new HCV infections. We estimated incremental cost-effectiveness ratios (ICERs), and assessed uncertainty using cost-effectiveness acceptability curves (CEACs). For each scenario, we ran the intervention for 10 years and evaluated costs and benefits for a further 50 years. Costs and QALYs were discounted at 3% annually.

Results: For both settings, I1 is not cost-effective (weakly dominated by I2), and the appropriate comparator for I2 is the baseline scenario. Relative to baseline in PC, I2 was associated with 1,885 less infections, 3,182 QALYs gained and an increased cost of $18 million, giving an ICER of $3,047 per QALY gained. Relative to baseline in SF, I2 was associated with 36,473 less infections, 75,019 QALYs gained and an increased cost of $286 million, giving an ICER of $3,809 per QALY gained. For willingness to pay thresholds above $50,000 per QALY, I2 was the most cost-effective intervention in more than 95% of the simulations and for both settings.

Conclusion: Scaling up HCV treatment combined with MAT and SSP is a cost-effective approach for reducing HCV transmission in both rural and urban settings. This finding should help change policy to reduce disparities in the management of HCV infection and encourage support for HCV treatment in PWID to optimize population-level prevention benefits.