1 Section of Infectious Disease, Department of Medicine, Boston Medical Center, Boston, MA, USA.
2 Section of Infectious Disease, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
3 Grady Health System, Atlanta, GA, USA.
4 Prevention Branch, Division of Viral Hepatitis, Centers for Disease Control and Prevention, GA, USA.
5 Massachusetts Department of Public Health, Boston, MA, USA.
6 Division of Allergy & Infectious Disease, Department of Medicine, University of Washington, Seattle, WA, USA.
7 Washington State Department of Corrections, Tumwater, WA, USA.
8 Stanford University School of Medicine, Stanford, CA, USA.
9 Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
Hepatitis C virus (HCV) testing and treatment uptake in prisons remains low. We aimed to estimate clinical outcomes, cost-effectiveness (CE), and budgetary impact (BI) of HCV testing and treatment in United States (U.S.) prisons or linkage to care at release.
We used individual-based simulation modeling with healthcare and Department of Corrections (DOC) perspectives for CE and BI analyses, respectively. We simulated a U.S. prison cohort at entry using published data and Washington State DOC individual-level data. We considered permutations of testing (risk factor-based, routine at entry or at release, no testing), treatment (if liver fibrosis ≥F3, for all HCV-infected or no treatment) and linkage to care (at release or no linkage). Outcomes included quality adjusted life years (QALY); cases identified, treated and cured; cirrhosis cases avoided; incremental cost-effectiveness ratios (ICER); DOC costs (2016 US $); and BI (healthcare cost/prison entrant) to generalize to other states.
Compared to "no testing, no treatment and no linkage to care", "test all, treat all, and linkage to care at release" increased the lifetime sustained virologic response by 23%, reduced cirrhosis cases by 54% at a DOC annual additional cost of $1,440/ prison entrant, and would be cost-effective. At current drug prices, targeted testing and liver fibrosis-based treatment provided worse outcomes at higher cost or worse outcomes at higher cost/QALY gained. In sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs.
Although costly, widespread testing and treatment in prisons are considered of good value at current drug prices.