Cost and cost-effectiveness of a simplified treatment model with direct-acting antivirals for chronic hepatitis C in Cambodia.

Josephine G Walker,Reuben A Hastings,David Maman,Momoko Iwamoto,Joanna Coast,Anne Loarec,Suna Balkan,Linda Campbell,Chamroeun San Kim,Peter Vickerman,Mickael Le Paih,Tonia Marquardt,Jean‐Philippe Doussett,Nyashadzaishe Mafirakureva

doi:10.1111/liv.14550

Josephine G Walker, Reuben A Hastings + Show 12 more

Open Access

https://doi.org/10.1111/liv.14550

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Abstract

In 2016, Médecins Sans Frontières established the first general population Hepatitis C virus (HCV) screening and treatment site in Cambodia, offering free direct-acting antiviral (DAA) treatment. This study analysed the cost-effectiveness of this intervention. Costs, quality adjusted life years (QALYs) and cost-effectiveness of the intervention were projected with a Markov model over a lifetime horizon, discounted at 3%/year. Patient-level resource-use and outcome data, treatment costs, costs of HCV-related healthcare and EQ-5D-5L health states were collected from an observational cohort study evaluating the effectiveness of DAA treatment under full and simplified models of care compared to no treatment; other model parameters were derived from literature. Incremental cost-effectiveness ratios (cost/QALY gained) were compared to an opportunity cost-based willingness-to-pay threshold for Cambodia ($248/QALY). The total cost of testing and treatment per patient for the full model of care was $925(IQR $668-1631), reducing to $376(IQR $344-422) for the simplified model of care. EQ-5D-5L values varied by fibrosis stage: decompensated cirrhosis had the lowest value, values increased during and following treatment. The simplified model of care was cost saving compared to no treatment, while the full model of care, although cost-effective compared to no treatment ($187/QALY), cost an additional $14 485/QALY compared to the simplified model, above the willingness-to-pay threshold for Cambodia. This result is robust to variation in parameters. The simplified model of care was cost saving compared to no treatment, emphasizing the importance of simplifying pathways of care for improving access to HCV treatment in low-resource settings.

Highlights

The World Health Organization (WHO) estimated that 71 million people were infected with the Hepatitis C virus (HCV) globally in 2015.1 Most (80%) HCV infections are in low- and middle-income countries (LMIC),[2] but fewer than 5% of these patients are diagnosed.[3]HCV is a major contributor to liver cancer and overall cancer deaths in Cambodia and Asia.[4,5] Southeast Asia has the second highest burden of viral hepatitis mortality globally.[1]
The simplified model of care was cost saving compared to no treatment, emphasizing the importance of simplifying pathways of care for improving access to HCV treatment in low-resource settings
This study evaluated the cost-effectiveness of Médecins Sans Frontières (MSF)'s HCV treatment program in Cambodia[10] in terms of cost per quality adjusted life year (QALY) gained using a Markov state-transition model representing the lifetime disease progression of a cohort of HCV-infected patients

Summary

Introduction

The World Health Organization (WHO) estimated that 71 million people were infected with the Hepatitis C virus (HCV) globally in 2015.1 Most (80%) HCV infections are in low- and middle-income countries (LMIC),[2] but fewer than 5% of these patients are diagnosed.[3]HCV is a major contributor to liver cancer and overall cancer deaths in Cambodia and Asia.[4,5] Southeast Asia has the second highest burden of viral hepatitis mortality globally.[1]. Direct-acting antivirals (DAAs) offer an effective cure for HCV with few side effects Access to these medicines, has been limited by their high cost, alongside the cost of diagnostics and the infrastructure required for scaling up treatment.[3,8] In Cambodia, healthcare expenditure per capita is low ($69 in 2012); of this 60% comes from patient out of pocket expenses.[9] Despite limited funding, ongoing government health initiatives provide tuberculosis, malaria and HIV/AIDS treatment free at the point of care. The simplified model of care was cost saving compared to no treatment, while the full model of care, cost-effective compared to no treatment ($187/QALY), cost an additional $14 485/QALY compared to the simplified model, above the willingness-to-pay threshold for Cambodia This result is robust to variation in parameters

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