1Division of Global Public Health, University of California San Diego, USA.
2School of Social and Community Medicine, University of Bristol, UK.
3Leeds Community Healthcare NHS Trust, UK.
4London School of Hygiene and Tropical Medicine, UK.
5University of Nottingham, UK.
6County Durham and Darlington NHS Trust, UK.
7Glasgow Caledonian University, UK.
8Public Health England, UK.
Prisoners have a high prevalence of Hepatitis C virus (HCV), but case-finding may not have been cost-effective because treatment often exceeded average prison stay combined with a lack of continuity-of-care. We assess the cost-effectiveness of increased HCV case-finding and treatment in UK prisons using short-course therapies.
A dynamic HCV transmission model assesses the cost-effectiveness of doubling HCV case-finding (achieved through introducing opt-out HCV testing in UK pilot prisons) and increasing treatment in UK prisons, compared to status-quo voluntary risk-based testing (6% prison entrants/year), using currently recommended therapies(8-24 weeks) or IFN-free DAAs(8-12 weeks, 95% SVR, £3300/wk). Costs(GBP£) and health utilities(quality-adjusted life-years,QALYs) were used to calculate mean incremental cost-effectiveness ratios(ICERs). We assume 56% referral and 2.5%/25% of referred people who inject drugs(PWID)/exPWID treated within 2 months of diagnosis in prison. PWID and ex/nonPWID are in prison an average 4/8 months, respectively.
Doubling prison testing rates with existing treatments produces a mean ICER of £19,850/QALY gained compared to current testing/treatment, and is 45% likely to be cost-effective under a £20,000 willingness-to-pay(WTP) threshold. Switching to 8-12 week IFN-free DAAs in prisons could increase cost-effectiveness(ICER £15,090/QALY gained). Excluding prevention benefit decreases cost-effectiveness. If >10% referred PWID are treated in prison (2.5% base-case), either treatment could be highly cost-effective(ICER<£13,000). HCV case-finding and IFN-free DAAs could be highly cost-effective if DAA cost is 10% lower or 8 weeks duration.
Conclusions Increased HCV testing in UK prisons (such as through opt-out testing) is borderline cost-effective compared to status-quo voluntary risk-based testing under a £20,000 WTP with current treatments, but likely to be cost-effective if short-course IFN-free DAAs are used, and could be highly cost-effective if PWID treatment rates were increased.