Advertisement

Assessing the cost-effectiveness of hepatitis C screening strategies in France

      Highlights

      • In France, universal screening is the most effective strategy for HCV.
      • Universal screening is cost-effective at the threshold of 1–3 times GDP per capita.
      • Cost-effectiveness mainly depends on utility values and time to treatment initiation.

      Background & Aims

      In Europe, hepatitis C virus (HCV) screening still targets people at high risk of infection. We aim to determine the cost-effectiveness of expanded HCV screening in France.

      Methods

      A Markov model simulated chronic hepatitis C (CHC) prevalence, incidence of events, quality-adjusted life years (QALYs), costs and incremental cost-effectiveness ratio (ICER) in the French general population, aged 18 to 80 years, undiagnosed for CHC for different strategies: S1 = current strategy targeting the at risk population; S2 = S1 and all men between 18 and 59 years; S3 = S1 and all individuals between 40 and 59 years; S4 = S1 and all individuals between 40 and 80 years; S5 = all individuals between 18 and 80 years (universal screening). Once CHC was diagnosed, treatment was initiated either to patients with fibrosis stage ≥F2 or regardless of fibrosis. Data were extracted from published literature, a national prevalence survey, and a previously published mathematical model. ICER were interpreted based on one or three times French GDP per capita (€32,800).

      Results

      Universal screening led to the lowest prevalence of CHC and incidence of events, regardless of treatment initiation. When considering treatment initiation to patients with fibrosis ≥F2, targeting all people aged 40–80 was the only cost-effective strategy at both thresholds (€26,100/QALY). When we considered treatment for all, although universal screening of all individuals aged 18–80 is associated with the highest costs, it is more effective than targeting all people aged 40–80, and cost-effective at both thresholds (€31,100/QALY).

      Conclusions

      In France, universal screening is the most effective screening strategy for HCV. Universal screening is cost-effective when treatment is initiated regardless of fibrosis stage. From an individual and especially from a societal perspective of HCV eradication, this strategy should be implemented.

      Lay summary

      In the context of highly effective and well tolerated therapies for hepatitis C virus that are now recommended for all patients, a reassessment of hepatitis C screening strategies is needed. An effectiveness and cost-effectiveness study of different strategies targeting either the at-risk population, specific ages or all individuals was performed. In France, universal screening is the most effective strategy and is cost-effective when treatment is initiated regardless of fibrosis stage. From an individual and especially from a societal perspective of hepatitis C virus eradication, this strategy should be implemented.

      Graphical abstract

      Keywords

      To read this article in full you will need to make a payment
      Subscribe to Journal of Hepatology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • European Centre for Disease Prevention and Control
        Hepatitis B and C in the EU neighbourhood: prevalence, burden of disease and screening policies.
        ECDC, Stockholm2010
        • Meffre C.
        • Le Strat Y.
        • Delarocque-Astagneau E.
        • Dubois F.
        • Antona D.
        • Lemasson J.M.
        • et al.
        Prevalence of hepatitis B and hepatitis C virus infections in France in 2004: social factors are important predictors after adjusting for known risk factors.
        J Med Virol. 2010; 82: 546-555
        • Brouard C.
        • Le Strat Y.
        • Larsen C.
        • Jauffret-Roustide M.
        • Lot F.
        • Pillonel J.
        The undiagnosed chronically-infected HCV population in France. Implications for expanded testing recommendations in 2014.
        PLoS One. 2015; 10e0126920
        • Delarocque-Astagneau E.
        • Meffre C.
        • Dubois F.
        • Pioche C.
        • Le Strat Y.
        • Roudot-Thoraval F.
        • et al.
        The impact of the prevention programme of hepatitis C over more than a decade: the French experience.
        J Viral Hepat. 2010; 17: 435-443
        • Brouard C.
        • Delarocque Astagneau E.
        • Meffre C.
        • Pioche C.
        • Silvain C.
        • Larsen C.
        • et al.
        Trends of hepatitis C screening in France through Rena-VHC and hepatology reference centres surveillance system, 2000–2007.
        Bull Epidemiol Hebd. 2009; 20–21: 199-204
        • Arends J.E.
        • Kracht P.A.
        • Hoepelman A.I.
        • on behalf of the European Study Group for Viral Hepatitis (ESGVH)
        Performance of hepatitis C virus (HCV) direct-acting antivirals in clinical trials and daily practice.
        Clin Microbiol Infect. 2016; 22: 846-852
        • Chevaliez S.
        • Poiteau L.
        • Rosa I.
        • Soulier A.
        • Roudot-Thoraval F.
        • Laperche S.
        • et al.
        Prospective assessment of rapid diagnostic tests for the detection of antibodies to hepatitis C virus, a tool for improving access to care.
        Clin Microbiol Infect. 2016; 22: e451-e456
        • Smith B.D.
        • Morgan R.L.
        • Beckett G.A.
        • Falck-Ytter Y.
        • Holtzman D.
        • Ward J.W.
        Hepatitis C virus testing of persons born during 1945–1965: recommendations from the Centers for Disease Control and Prevention.
        Ann Intern Med. 2012; 157: 817-822
        • Grebely J.
        • Bilodeau M.
        • Feld J.J.
        • Bruneau J.
        • Fischer B.
        • Raven J.F.
        • et al.
        The Second Canadian Symposium on hepatitis C virus: a call to action.
        Can J Gastroenterol. 2013; 27: 627-632
      1. Canadian liver foundation. Position statement – hepatitis C testing; 2012.

        • Deuffic-Burban S.
        • Deltenre P.
        • Buti M.
        • Stroffolini T.
        • Parkes J.
        • Muhlberger N.
        • et al.
        Predicted effects of treatment for HCV infection vary among European countries.
        Gastroenterology. 2012; 143 (e914): 974-985
        • Deuffic-Burban S.
        • Boursier J.
        • Leroy V.
        • Yazdanpanah Y.
        • Castera L.
        • Mathurin P.
        Are targeted treatment recommendations in chronic hepatitis C tailored to diagnostic methods of fibrosis?.
        J Hepatol. 2017; 66: 304-312
        • Schwarzinger M.
        • Deuffic-Burban S.
        • Mallet V.
        • Pol S.
        • Pageaux G.P.
        • Canva-Delcambre V.
        • et al.
        Lifetime costs attributable to chronic hepatitis C from the French healthcare perspective (Anrs N 12188).
        J Hepatol. 2013; 58: S21-S22
        • Cousien A.
        • Tran V.C.
        • Deuffic-Burban S.
        • Jauffret-Roustide M.
        • Dhersin J.S.
        • Yazdanpanah Y.
        Hepatitis C treatment as prevention of viral transmission and liver-related morbidity in persons who inject drugs.
        Hepatology. 2016; 63: 1090-1101
      2. Prise en charge thérapeutique et suivi de l'ensemble des personnes infectées par le virus de l’hépatite C. Rapport de recommandations 2016: Sous la direction du Pr Daniel Dhumeaux. Sous l’égide de l’ANRS et du CNS et avec le concours de l’AFEF.

        • Gold M.R.
        • Siegel J.E.
        • Russell L.B.
        • Weinstein M.C.
        Cost effectiveness in health and medicine.
        Oxford University Press, New-York1996
      3. HAS Haute Autorité de Santé. Guide méthodologique: Choix méthodologiques pour l'évaluation économique à la HAS. Octobre 2011: Haute Autorité de Santé; 2011.

      4. Index mundi. World GDP - per capita (PPP). [cited 12 February 2018]; Available from: https://www.indexmundi.com/world/gdp_per_capita_(ppp).html.

        • WHO
        Making choices in health: WHO guide to cost-effectiveness analysis.
        WHO, Geneva2003
        • Neumann P.J.
        • Cohen J.T.
        • Weinstein M.C.
        Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold.
        N Engl J Med. 2014; 371: 796-797
        • Deuffic-Burban S.
        • Obach D.
        • Canva V.
        • Pol S.
        • Roudot-Thoraval F.
        • Dhumeaux D.
        • et al.
        Cost-effectiveness and budget impact of interferon-free direct-acting antiviral-based regimens for hepatitis C treatment: the French case.
        J Viral Hepat. 2016; 23: 767-779
        • Corrao G.
        • Arico S.
        Independent and combined action of hepatitis C virus infection and alcohol consumption on the risk of symptomatic liver cirrhosis.
        Hepatology. 1998; 27: 914-919
        • Deuffic-Burban S.
        • Mathurin P.
        • Pol S.
        • Larsen C.
        • Roudot-Thoraval F.
        • Desenclos J.C.
        • et al.
        Impact of hepatitis C triple therapy availability upon the number of patients to be treated and associated costs in France: a model-based analysis.
        Gut. 2012; 61: 290-296
        • European Association for the Study of the Liver
        EASL recommendations on treatment of hepatitis C 2016.
        J Hepatol. 2017; 66: 153-194
        • van der Meer A.J.
        • Veldt B.J.
        • Feld J.J.
        • Wedemeyer H.
        • Dufour J.F.
        • Lammert F.
        • et al.
        Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis.
        JAMA. 2012; 308: 2584-2593
        • Deuffic-Burban S.
        • Schwarzinger M.
        • Obach D.
        • Mallet V.
        • Pol S.
        • Pageaux G.P.
        • et al.
        Should we await IFN-free regimens to treat HCV genotype 1 treatment-naive patients? A cost-effectiveness analysis (ANRS 95141).
        J Hepatol. 2014; 61: 7-14
      5. AFEF. Recommandations AFEF sur la prise en charge de l'hépatite virale C: Société Française d'Hépatologie; 2017 Mars 2017.

      6. Ministère des Affaires sociales et de la Santé. Accès universel aux traitements innovants contre l’hépatite C: Après avoir permis l’accès de tous les malades aux traitements, Marisol Touraine obtient une baisse de prix importante. Paris.

        • Chevalier J.
        • de Pouvourville G.
        Valuing EQ-5D using time trade-off in France.
        Eur J Health Econ. 2013; 14: 57-66
        • Pol S.
        • Chevalier J.
        • Branchoux S.
        • Perry R.
        • Milligan G.
        • Gaudin A.-F.
        Health related quality of life and utility values in chronic hepatitis C patients: A cross-sectional study in France, the UK and Germany (P0747).
        J Hepatol. 2015; 62: S606
        • Chong C.A.
        • Gulamhussein A.
        • Heathcote E.J.
        • Lilly L.
        • Sherman M.
        • Naglie G.
        • et al.
        Health-state utilities and quality of life in hepatitis C patients.
        Am J Gastroenterol. 2003; 98: 630-638
      7. Prise en charge des personnes infectées par les virus de l’hépatite B ou de l’hépatite C. Rapport de recommendations 2014: Sous la direction du Pr Daniel Dhumeaux et sous l’égide de l’ANRS et de l’AFEF.

        • Bottero J.
        • Brouard C.
        • Roudot-Thoraval F.
        • Deuffic-Burban S.
        • Hofliger P.
        • Abergel A.
        • et al.
        2014 French guidelines for hepatitis B and C screening: a combined targeted and mass testing strategy of chronic viruses namely HBV, HCV and HIV.
        Liver Int. 2016; 36: 1442-1449
      8. Synthèse de la recommandation en santé publique - Réévaluation de la stratégie de dépistage de l'infection à VIH en France – Mars 2017. [cited April 3, 2018]; Available from: https://www.has-sante.fr/portail/upload/docs/application/pdf/2017–03/dir2/reevaluation_de_la_strategie_depistage_vih_-_synthese_reco.pdf.

        • Moyer V.A.
        • U.S. Preventive Services Task Force
        Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2013; 159: 349-357
        • Rein D.B.
        • Smith B.D.
        • Wittenborn J.S.
        • Lesesne S.B.
        • Wagner L.D.
        • Roblin D.W.
        • et al.
        The cost-effectiveness of birth-cohort screening for hepatitis C antibody in U.S. primary care settings.
        Ann Intern Med. 2012; 156: 263-270
        • McGarry L.J.
        • Pawar V.S.
        • Panchmatia H.R.
        • Rubin J.L.
        • Davis G.L.
        • Younossi Z.M.
        • et al.
        Economic model of a birth cohort screening program for hepatitis C virus.
        Hepatology. 2012; 55: 1344-1355
        • Coffin P.O.
        • Scott J.D.
        • Golden M.R.
        • Sullivan S.D.
        Cost-effectiveness and population outcomes of general population screening for hepatitis C.
        Clin Infect Dis. 2012; 54: 1259-1271
        • Liu S.
        • Cipriano L.E.
        • Holodniy M.
        • Goldhaber-Fiebert J.D.
        Cost-effectiveness analysis of risk-factor guided and birth-cohort screening for chronic hepatitis C infection in the United States.
        PLoS One. 2013; 8e58975
        • McEwan P.
        • Ward T.
        • Yuan Y.
        • Kim R.
        • L'Italien G.
        The impact of timing and prioritization on the cost-effectiveness of birth cohort testing and treatment for hepatitis C virus in the United States.
        Hepatology. 2013; 58: 54-64
        • Rein D.B.
        • Wittenborn J.S.
        • Dougherty M.C.
        The Cost-effectiveness of a one time hepatitis C virus antibody test followed by treatment for all Americans ages 18 and older as compared to current testing recommendations in the United States.
        J Hepatol. 2017; 66: S405
        • Barocas J.A.
        • Tasillo A.
        • Eftekhari Yazdi G.
        • Wang J.
        • Vellozzi C.
        • Hariri S.
        • et al.
        Population level outcomes and cost-effectiveness of expanding the recommendation for age-based hepatitis C testing in the United States.
        Clin Infect Dis. 2018; ([Epub ahead of print])
        • Eckman M.H.
        • Talal A.H.
        • Gordon S.C.
        • Schiff E.
        • Sherman K.E.
        Cost-effectiveness of screening for chronic hepatitis C infection in the United States.
        Clin Infect Dis. 2013; 56: 1382-1393
        • Wong W.W.
        • Tu H.A.
        • Feld J.J.
        • Wong T.
        • Krahn M.
        Cost-effectiveness of screening for hepatitis C in Canada.
        CMAJ. 2015; 187: E110-E121
        • Canadian Task Force on Preventive Health C
        Recommendations on hepatitis C screening for adults.
        CMAJ. 2017; 189: E594-E604
        • Dusheiko G.
        The impact of antiviral therapy for hepatitis C on the quality of life: a perspective.
        Liver Int. 2017; 37: 7-12
        • Cousien A.
        • Tran V.C.
        • Deuffic-Burban S.
        • Jauffret-Roustide M.
        • Mabileau G.
        • Dhersin J.S.
        • et al.
        Effectiveness and cost-effectiveness of interventions targeting harm reduction and chronic hepatitis C cascade of care in people who inject drugs; the case of France.
        J Viral Hepat. 2018; ([Epub ahead of print])