IAME, UMR 1137, INSERM, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France.
Inserm, LIRIC-UMR995, Univ LilleF-59000 Lille, France.
CERMES3: Centre de Recherche Médecine, Sciences, Santé, Santé Mentale et Société, (INSERM U988/UMR CNRS8211/Université Paris Descartes, Ecole des Hautes Etudes en Sciences Sociales), ParisFrance.
Institut de Veille Sanitaire, Saint-Maurice, France.
Université Paris 13, Sorbonne Paris Cité, LAGA, CNRS, UMR 7539, F-93430, Villetaneuse, France.
Service des Maladies Infectieuses et Tropicales, Hôpital Bichat Claude Bernard, Paris, France.
Direct-acting antivirals (DAAs) represent an opportunity to improve hepatitis C virus (HCV) care cascade. This, combined with improved harm reduction interventions may lead to HCV elimination especially in people who inject drugs (PWID). We assessed the effectiveness/cost-effectiveness of improvements in harm reduction and chronic hepatitis C (CHC) care cascade in PWID in France. We used a dynamic model of HCV transmission and CHC natural history and evaluated: improved needle/syringe programs-opioid substitution therapies, faster diagnosis/linkage to care, earlier treatment initiation, alone and in combination among active PWID (mean age=36). Outcomes were: life expectancy in discounted quality-adjusted life-years (QALYs); direct lifetime discounted costs; incremental cost-effectiveness ratio (ICER); number of infections/reinfections. Under the current practice, life expectancy was 15.846 QALYs, for a mean lifetime cost of €20,762. Treatment initiation at F0 fibrosis stage alone was less effective and more costly than faster diagnosis/linkage to care combined with treatment initiation at F0, that increased life expectancy to 16.694 QALYs, decreased new infections by 37%, with a ICER=€5,300/QALY. Combining these interventions with harm reduction improvements was the most effective scenario (life expectancy =16.701 QALYs, 41% decrease in new infections) but was not cost-effective (ICER= €105,600/QALY); it became cost-effective with higher initial HCV incidence rates and lower harm reduction coverage than in our base-case scenario. This study illustrated the high effectiveness, and cost-effectiveness, of a faster diagnosis/linkage to care together with treatment from F0 with DAAs. This "Test and treat" strategy should play a central role both in improving the life expectancies of HCV-infected patients, and in reducing HCV transmission.