HCV Testing and Treatment in Prisons Improves Outcomes, But At What Price?

Testing and treating for hepatitis C virus (HCV) in prisons could be the key to reducing transmissions out in the community. However, a new study has found that, although the price of HCV drugs has decreased, these approaches would consume a large portion of prisons’ pharmaceutical and health care budgets.

HCV infection is the most common blood-borne infection in the United States and seroprevalence in correctional settings is estimated to be 13-fold higher than in the general population and accounts for approximately 30% of the national HCV burden.

Uptake of HCV testing and treatment in the prison setting remains low and, even though providers and policymakers are aware of the importance of treatment, gaps remain in available data regarding the cost-effectiveness and affordability, which inhibits progress in eliciting change.

Therefore, a team of investigators set out to estimate clinical outcomes, cost-effectiveness, and budgetary impact of HCV testing and treatment in US prisons. The study team, led by an investigator from Boston Medical Center, published their findings recently in the journal Clinical Infectious Diseases.

For the study, the investigators simulated a prison cohort at entry using published data alongside Washington State DOC individual-level data. The team used an individual-based simulation model with health care and department of corrections perspectives for cost-effectiveness and budgetary impact analyses, respectively.

The study focused on outcomes including “quality adjusted life years (QALY); cases identified, treated and cured; cirrhosis cases avoided; incremental cost-effectiveness rations; DOC costs; and BI health care/prison entrant to generalize to other states.” To determine outcomes, the investigators considered various elements, including testing (risk-factor based, routine at entry and/or release, or no testing), treatment (liver fibrosis >F3, for all individuals with HCV, or no treatment), and linkage to care (at point of release or no linkage).

Findings from the study indicate that compared with not providing testing, treatment, and linkage to care, the approach of “test all, treat all, and linkage to care at release” increased the lifetime sustained virologic response by 23% and reduced cirrhosis cases by 54%; however, this approach incurred an additional annual cost of $1440 per prison entrant to the Department of Corrections.

According to the investigators, current drug prices, targeted testing, and liver fibrosis-based treatment provided worse outcomes at a higher cost or worse outcomes at higher cost/QALY gained. But, in sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs.

Based on these findings, the authors report that although the “test all, treat all, and linkage to care,” is costly, it is considered of good value at current drug prices.

"We expected clinical outcomes to improve with widespread testing, treatment, and linkage to care for individuals not treated in prisons, but found it notable that it was also the strategy to most efficiently use limited health resources," Sabrina Assoumou, MD, MPH, infectious diseases physician at BMC and the study's lead author, said in a press release. "Addressing HCV in prisons will require investment from departments of corrections and public health departments, but we hope these findings demonstrate the value of such an investment and will encourage innovations in financing HCV care among this population."

The investigators also report that the study was supported by the US Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention Epidemiologic and Economic Modeling Agreement and the National Institute of Drug Abuse and the National Institute of Allergy and Infectious Diseases.