May 30, 2019
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‘Test all, treat all’ approach to HCV cost-effective in US prisons

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Researchers found that widespread hepatitis C virus testing and treatment in prison, and linking patients not treated in prison to care upon release, is “cost-effective, but costly.”

“Approximately 30% of HCV-infected people in the United States pass through the prison system annually. Previous studies demonstrate that HCV testing and treatment in prisons is likely cost-effective, and that it may reduce HCV transmission in the community. A gap remains, however, between the value-for-money (cost-effectiveness) and the affordability of such strategies (budgetary impact),” Sabrina A. Assoumou, MD, MPH, an infectious disease physician at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine, and colleagues wrote.

“Real-world correctional systems often feel ill prepared and underfunded to lead the public health mission of HCV elimination. Providers and policymakers in correctional settings know that HCV treatment is important, but they need data to inform the costs and outcomes they can expect to accrue from a variety of realistic and practical testing and treating algorithms. Our goal, therefore, was to evaluate the clinical benefit and budgetary impact of multiple, realistic and feasible HCV testing and treatment strategies in U.S. state prisons.”

Using data from the Washington State Department of Corrections, Assoumou and colleagues adapted an existing HCV cost-effectiveness model to simulate the lifespan of incarcerated HCV-infected and -noninfected adults “and their transitions between prison and the community.” They compared 15 strategies for HCV testing and treatment, with permutations that included methods ranging from no testing or treatment to routine testing at intake or release and universal treatment, provided patents had at least 12 months remaining on their sentence.

According to the study, the researchers found that a “test all, treat all, and linkage to care at release” method increased the lifetime SVR among patients by 23% and reduced cirrhosis cases by 54% at an annual additional cost of $1,440 per person for the department of corrections.

Assoumou and colleagues said that, at current drug prices, targeted testing and treatment based on liver fibrosis stage provided worse outcomes at higher cost or worse outcomes at higher cost per quality adjusted life year gained and that, in a sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs.

“Given the decrease in HCV drug costs, commonly used and intuitive cost-control strategies — targeted testing and/or treatment restrictions to individuals with advanced disease — may not lead to the best allocation of limited resources, or to the best population health outcomes. Nevertheless, even with recent decreases in drug costs, ‘test all, treat all, and linkage to care’ would consume the majority of a state prison system’s pharmaceutical budget in most states,” the researchers concluded. “Addressing HCV in prisons will require investment in correctional health and partnerships, including with public health departments.” – by Caitlyn Stulpin

Disclosures: The authors report no relevant financial disclosures.