Is increased hepatitis C virus case‐finding combined with current or 8‐week to 12‐week direct‐acting antiviral therapy cost‐effective in UK prisons? A prevention benefit analysis

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 assessed 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 interferon (IFN)‐free direct‐acting antivirals (DAAs; 8‐12 weeks, 95% sustained virological response, £3300/week). Costs (British pounds, £) and health utilities (quality‐adjusted life years) were used to calculate mean incremental cost‐effectiveness ratios (ICERs). We assumed 56% referral and 2.5%/25% of referred people who inject drugs (PWID)/ex‐PWID treated within 2 months of diagnosis in prison. PWID and ex‐PWID or non‐PWID are in prison an average 4 and 8 months, respectively. Doubling prison testing rates with existing treatments produces a mean ICER of £19,850/quality‐adjusted life years gained compared to current testing/treatment and is 45% likely to be cost‐effective under a £20,000 willingness‐to‐pay threshold. Switching to 8‐week to 12‐week IFN‐free DAAs in prisons could increase cost‐effectiveness (ICER £15,090/quality‐adjusted life years 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 with 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 willingness to pay 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. (Hepatology 2016;63:1796‐1808)