Hepatitis C: cost of illness and considerations for the economic evaluation of antiviral therapies

Perceptions, Attitudes, and Behaviors Related to Hepatitis Among the General Population Attending a COVID-19 Vaccination Center in a Tertiary Care Hospital in India

Background and objective Hepatitis B and C are major public health issues in India, associated with significant morbidity and mortality. Understanding the general population's perceptions, values, attitudes, and behaviors regarding these infections is essential for effective health interventions. In light of this, the present study aimed to assess the knowledge, attitude, and practice (KAP) related to hepatitis B and C among individuals attending a coronavirus disease 2019 (COVID-19) vaccination center at a tertiary care hospital in India. Methods A cross-sectional survey involving 759 participants was conducted using a structured questionnaire. Data on demographics and hepatitis-related KAP were collected via face-to-face interviews. Descriptive statistics, chi-square tests, multivariate logistic regression, and Pearson's correlation coefficients were used for data analysis. Results The mean age of the participants was 33.4 years, with 445 (58.6%) of them being males. Most had at least a high school education, and 467 (61.53%) were employed. The mean knowledge score was 18.94 out of a possible total score of 45. While 529 (69.7%) knew that hepatitis affects the liver, only 317 (41.77%) were aware of the various types of viral hepatitis. The mean attitude score was 15.28 out of 21, with 78.73% willing to seek treatment if diagnosed. However, only 133 (17.55%) believed they were at risk of contracting hepatitis B. The mean practice score was 7.95 out of 15. About 256 (33.73%) had completed the hepatitis B vaccination course and 186 (24.5%) had been screened for hepatitis B or C. Conclusions The study indicates moderate knowledge but significant gaps in understanding about hepatitis transmission and prevention among the general public. Attitudes towards vaccination and treatment are generally positive, but practices related to prevention are inconsistent. Enhanced public health education and targeted interventions are needed to improve hepatitis-related KAP among the general population.

Hepatitis C prevalence and cascade of care among patients in the decentralised opioid agonist therapy programme of the canton of St Gallen, Switzerland: a cross-sectional study

BACKGROUND

To eliminate chronic hepatitis C virus (HCV) infection by 2030, 90% of those infected must be diagnosed and 80% treated. In Switzerland, >40% of the estimated 32,000 infected people are still undiagnosed. In the canton of St Gallen, HCV prevalence and cascade of care have only been studied in the centralised opioid agonist therapy (OAT) setting (institutions), although about 80% of OAT patients are treated decentrally (general practitioner [GP] or pharmacy).

AIM

To describe HCV prevalence and cascade of care among patients in the decentralised OAT programme of the canton of St Gallen, Switzerland, and compare it to contemporaneous data from the centralised setting.

METHODS

For each patient receiving his/her OAT from a GP or pharmacy on 1 April 2021, the cantonal medical office sent a questionnaire to the prescribing GP. Patient characteristics, HCV antibody (Ab)/RNA screening uptake, HCV Ab/RNA prevalence and HCV treatment uptake were obtained and compared to those of patients of the Medizinisch-soziale Hilfsstelle 1 in St Gallen (centralised setting).

RESULTS

Of the 563 OAT patients under the care of 127 GPs, 107 patients from 41 GPs could be analysed (median age: 48 years [IQR: 40-56]; ongoing intravenous drug use: 25%; OAT provider: 66% GP, 34% pharmacy). HCV Ab screening uptake was 68% (73/107) with an HCV Ab prevalence of 68% (50/73) among those tested. Of the HCV Ab-positive patients, 84% (42/50) were HCV RNA-tested, among whom 57% (24/42) were viraemic. HCV treatment uptake was 83% (20/24), with 95% (19/20) achieving a sustained virological response. Non-uptake of HCV screening and treatment tended to be higher among patients receiving OAT at the pharmacy vs at the GP's office: 37% vs 26% (p = 0.245) for screening and 30% vs 7% (p = 0.139) for treatment. The proportion never HCV Ab-tested and the proportion of HCV Ab-positives never HCV RNA-tested was significantly higher in the decentralised compared to the centralised setting: 32% vs 3% (p <0.001) never Ab-tested and 16% vs 0% (p = 0.002) never RNA-tested. In contrast, HCV treatment uptake (83% vs 78%), sustained virological response rate (95% vs 100%) and residual HCV RNA prevalence among the HCV Ab-positive (12% vs 14%) were comparable for both settings.

CONCLUSION

In the decentralised OAT setting of the canton of St Gallen, HCV Ab prevalence is high. Since HCV Ab and RNA screening uptake are markedly lower than in the centralised setting, potentially >40% of patients with chronic HCV are not diagnosed yet. HCV screening in the decentralised setting needs improvement, e.g. by increasing awareness and simplifying testing. High HCV treatment uptake and cure rates are possible in centralised and decentralised settings.

The role of insurance providers in supporting treatment and management of hepatitis C patients

Today, one of the most important global public health challenges is represented by hepatitis C virus (HCV), which imposes relevant costs. Globally speaking, the median cost of HCV-related complications ranges from $280 for an uncomplicated hepatitis to $139,070 for a liver transplantation. There are effective therapies for HCV patients worldwide, which has increased the hope of improving the process of managing and curing these patients. The adherence of patients to the pharmacological treatment and the use of effective drugs in the management of HCV disease are of crucial importance for health policy- and decision-makers. Studies show that, globally, insurance coverage for patients with HCV is not adequate in that still many patients are not covered by insurance programs. This issue as well as the economic conditions of countries are very serious challenges for ensuring an effective treatment. The most important and greatest help currently available to ensure HCV treatment is to implement plans to reduce costs and support patients. Some studies have shown that the expansion of coverage by private payers seems able to generate positive spillover benefits to public insures. Insurers, in addition to maintaining and increasing their own interests, are trying to increase their social status as a sponsor of patients. In conclusion, HCV disease requires serious policies and affordable insurance coverage.

Significant reduction in end-stage liver diseases burden through the national viral hepatitis therapy program in Taiwan

A national viral hepatitis therapy program was launched in Taiwan in October 2003. This study aimed to assess the impact of the program on reduction of end-stage liver disease (ESLD) burden. Profiles of national registries of households, cancers, and death certificates were used to derive incidence and mortality of ESLDs from 2000 to 2011. Age-gender-adjusted incidence and mortality rates of hepatocellular carcinoma (HCC) and chronic liver diseases (CLDs) and cirrhosis of adults ages 30-69 years were compared before and after launching the program using Poisson's regression models. A total of 157,570 and 61,823 patients (15%-25% of those eligible for reimbursed treatment) received therapy for chronic hepatitis B and C, respectively, by 2011. There were 42,526 CLDs and cirrhosis deaths, 47,392 HCC deaths, and 74,832 incident HCC cases occurred in 140,814,448 person-years from 2000 to 2011. Male gender and elder age were associated with a significantly increased risk of CLDs and cirrhosis and HCC. Mortality and incidence rates of ESLDs decreased continuously from 2000 to 2003 (before therapy program) through 2004-2007 to 2008-2011 in all age and gender groups. The age-gender-adjusted rate ratio (95% confidence interval; P value) in 2008-2011 was 0.78 (0.76-0.80; P < 0.001) for CLDs and cirrhosis mortality, 0.76 (0.75-0.78; P < 0.005) for HCC mortality, and 0.86 (0.85-0.88; P < 0.005) for HCC incidence using 2000-2003 as the reference period (rate ratio = 1.0).

CONCLUSIONS

The national viral hepatitis therapy program has significantly reduced the mortality of CLDs and cirrhosis and incidence and mortality of HCC.

A window of opportunity: maximizing the effectiveness of new HCV regimens in the United States with the expansion of the Affordable Care Act

Patients with chronic HCV have predictable overlapping comorbidities that reduce access to care. The Affordable Care Act (ACA) presents an opportunity to focus on the benefits of the medical home model for integrated chronic disease management. New, highly effective HCV treatment regimens in combination with the medical home model could reduce disease prevalence. We sought to address challenges posed by comorbidities in patients with chronic HCV infection and limitations within our health care system, and recommend solutions to maximize the public benefit from ACA and the new drug regimen.

Attitudes and Awareness Regarding Hepatitis B and Hepatitis C Amongst Health-care Workers of a Tertiary Hospital in India

Background:

Hepatitis is an inflammatory disease of the liver. In sever cases, it may lead to permanent liver damage including liver cirrhosis or hepato-cellular carcinoma and may ultimately lead to death. Health-care workers (HCWs), due to their regular contact with patients are at a high-risk of acquiring this disease.

Aim:

The aim of this study was to assess the knowledge and attitude toward hepatitis B and C infection among the health-care interns and correlate the level of awareness to the attitude they behold toward the disease.

Subjects and Methods:

A closed ended questionnaire consisting of questions to evaluate the knowledge regarding hepatitis B and C infection and attitude of the (HCWs/interns) was duly filled by 255 participants including, 100 dental, 100 medical, and 55 nursing interns. Statistical analysis was carried out using the Chi-square test, ANOVA test, post-hoc test and Pearson's correlation.

Results:

Although most of the interns were aware of the existence of hepatitis B and C infection, the level of awareness regarding the modes of transmission and vaccination was found to be dissatisfactory. Awareness level regarding the infection among nursing interns was statistically significantly lower than the dental and medical interns. A direct positive correlation as found between awareness score and behavior score, which reveals that interns with better awareness level had better attitudes toward the infection and prevention of its transmission.

Conclusion:

There is an urgent need to increase the level and quality of training among HCWs to prevent the spread of hepatitis B virus and hepatitis C virus.

Resource Utilization and Direct Medical Costs of Chronic Hepatitis C in Thailand: A Heavy but Manageable Economic Burden

OBJECTIVE

To estimate the cost for the management of chronic hepatitis C (CHC) and related morbidities by using a payer perspective in Thailand.

METHODS

Data elements were extracted from medical records of 542 patients newly diagnosed with CHC in five tertiary care hospitals across Thailand. All patients were divided into five health states: noncirrhotic CHC, hepatitis C virus (HCV)-related compensated cirrhosis, HCV-related decompensated cirrhosis, HCV-related hepatocellular carcinoma, and HCV-related liver transplantation. Resource utilization data for each patient during a 12-month follow-up study period were compiled, and reference prices published by the Thai government were used to estimate the cost for each health state. The average cost was calculated and categorized into various groups, for example, laboratory and diagnostic tests, procedures, medication, and hospitalization.

RESULTS

The average number of outpatient visits per patient was approximately six visits in all cohorts. The HCV-related hepatocellular carcinoma and liver transplantation cohorts had a higher average number of inpatient admissions per patient. The average number of days per admission varied from fewer than 3 days to 1 week or more across all the health states. The average annual total cost per patient varied across all health states from approximately 170,000 to 600,000 baht, and medication cost was the largest portion in every cohort, except the HCV-related liver transplantation cohort in year 1. Among all medications, the average annual antiviral medication cost per patient was the largest portion in the noncirrhotic CHC and HCV-related compensated cirrhosis cohorts.

CONCLUSIONS

CHC was a costly disease in Thailand. The average annual medication cost was the largest portion in every health state, except HCV-related liver transplantation.

Hepatitis C: is a vaccine the solution?

Hepatitis C Virus (HCV) infection is a major cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Following acute infection, 20% of people eliminate the virus over weeks or months and are often asymptomatic. The remaining 80% of people will develop chronic disease, of which approximately 20% will eventually develop liver cirrhosis and 1-5% will develop liver cancer. About 150 million people are chronically infected with HCV, and more than 350,000 people die every year from hepatitis C related liver diseases. The economic cost of hepatitis C is significant both to the individual and to the society. In the United States the average lifetime cost of the disease was estimated at $33,407 USD with the cost of a liver transplant approximately $200,000 USD. PEG-IFN and ribavirin treatment is also expensive and, at an average cost of approximately GB £7000 in the UK for a treatment course, is unaffordable in developing countries. Hepatitis C, not only brings down the quality of the life of individuals but also affect progress of the nation by adding financial burden. If we prevent the disease from occurring or find a perfect cure of the disease, in form of a prophylactic or therapeutic vaccine, it will be a boon to not only to the individual but to the nation as a whole.

Costs of treatment, follow-up, and complications of chronic hepatitis B and hepatitis C infections

BACKGROUND

Few studies have addressed the indirect costs of chronic hepatitis B and C, and none has assessed the real costs of these conditions, including indirect costs caused by loss of work, in Turkey.

AIMS

This study therefore analysed the costs of treatment, follow-up, and complications of chronic hepatitis B and hepatitis C infections to the community.

STUDY DESIGN

Cross-sectional study.

METHODS

This study analysed patients with chronic hepatitis B and hepatitis C treated at Pamukkale University Hospital Infectious Diseases and Clinical Microbiology Clinic, Denizli, Turkey between June 2009 and June 2010. Costs of antiviral treatment and follow-up were calculated from patients' medical records, and indirect costs were analysed from questionnaires completed by patients.

RESULTS

Data were analysed for 284 patients with chronic viral hepatitis. Indirect, hospital, treatment and total expenses were significantly higher for patients with chronic hepatitis B than for inactive hepatitis B virus carriers and patients with chronic hepatitis C. Hospital and total expenses of patients with complications were significantly higher than for patients with chronic hepatitis C. Hospital and total expenses were significantly higher for patients with than for individuals without cirrhosis. Indirect, hospital, treatment and total costs of patients were significantly higher for patients receiving combination therapy than monotherapy.

CONCLUSION

Reducing the costs to society of chronic hepatitis requires the development of protection and screening programs.

Protease inhibitors for hepatitis C: economic implications

Chronic hepatitis C virus (HCV) infection, a blood-borne virus, is the leading cause of chronic liver disease and liver transplantation worldwide. Chronic HCV infection is usually asymptomatic in the early stages of the disease, making an estimation of the total population affected difficult to elicit. The gold standard treatment option to date has been a combination of pegylated interferon and ribavirin. Recent developments have led to the introduction of two protease inhibitors for use in chronic HCV-boceprevir and telaprevir. Phase III studies have shown both agents have the potential to significantly increase the probability of attaining a sustained virologic response (the primary outcome of interest in chronic HCV) in genotype 1 infections. However, the added cost of these agents also presents the need for decision makers to determine their place on drug formularies. The protease inhibitors are to be administered as triple therapy with the existing gold standard. However, significant variation exists as to the proposed duration of triple therapy, use of lead-in pegylated interferon and ribavirin and subsequent pegylated interferon therapy after finishing the course of triple therapy. Treatment algorithms also exist for the use of stopping rules in the case of early non-responders.The aim of this review is to highlight the current understanding of the economic impact protease inhibitors may have on health care systems and considerations required in the treatment of HCV. Economic and health-related quality of life issues are addressed from multiple viewpoints. The major aspects of the economic evaluations, to date, that included triple therapy as an alternative in the treatment of chronic HCV are brought to light. Future economic evaluations in alternative settings would be useful. The review also emphasizes the challenges for future research. This includes the potential for new therapies to no longer require inclusion of pegylated interferon and/or ribavirin, as well as the use of protease inhibitors in non-genotype 1 patients or those with significant co-morbidities such as HIV/AIDS.

Meta-analysis: pegylated interferon α-2a achieves higher early virological responses than α-2b in chronic hepatitis C

BACKGROUND

A Cochrane meta-analysis established that pegylated interferon α-2a is more effective than peginterferon α-2b in terms of sustained virological response (SVR) in the treatment of chronic hepatitis C. Rapid virological response (RVR) and early virological response (EVR) are crucial to reach SVR and to make clinical decisions.

AIM

To compare RVR and EVR rates of peginterferon α-2a vs. peginterferon α-2b through a meta-analysis of previously published randomised control trials (RCT).

METHODS

MEDLINE, EMBASE and LILACS databases were systematically searched up to September 2011. Seven RCT that reported complete early virological response (cEVR) were selected. A meta-analysis focusing on RVR and cEVR outcomes was conducted and Relative Efficacy (RE) was calculated.

RESULTS

Meta-analysis of cEVR included seven trials (n = 4359), and yielded an estimated effect in favour of peginterferon α-2a: Crude Efficacy (CEf) was 53.3% vs. 43.8%, RE = 1.118 (CI 95% = 1.039-1.203; P = 0.0028), heterogeneity Q = 8.959; I² = 33.0% (P = 0.1759). A sub-analysis of three studies with 3409 genotype-1 patients yielded CEf: 49.4% vs. 40.2%, RE = 1.151 (CI 95% = 0.968-1.369; P = 0.1124), Q = 9.802; I² = 79.6% (P = 0.0074). Meta-analysis of RVR included five trials (n = 3833) with an estimated effect in favour of peginterferon α-2a: CEf = 25.0% vs. 16.8%, RE = 1.151 (CI 95%:1.042-1.272; P = 0.0056), Q = 1.461;I² = 0.0% (P = 0.8335). Analysis of four studies reporting RVR including 3499 patients with genotypes 1 and 4 resulted in CEf: 18.3% vs. 12.7% RE = 1.206 (CI 95% = 1.059-1.374; P = 0.0048), Q = 1.116; I² = 0.0% (P = 0.7733).

CONCLUSIONS

Peginterferon α-2a may be associated with a higher cEVR and RVR than peginterferon α-2b. These findings could help to achieve higher SVR rates and support clinical decision-making in the present scenario of triple combination therapy.

Cost-effectiveness of screening for chronic hepatitis C infection in the United States

BACKGROUND

Hepatitis C virus (HCV) is the most common chronic blood-borne infection in the United States and will become an increasing source of morbidity and mortality with aging of the infected population. Our objective was to develop decision analytic models to explore the cost-effectiveness of screening in populations with varying prevalence of HCV and risks for fibrosis progression.

METHODS

We developed a Markov state transition model to examine screening of an asymptomatic community-based population in the United States. The base case was an ethnically and gender-mixed adult population with no prior knowledge of HCV status. Interventions were screening followed by guideline-based treatment, or no screening. Effectiveness was measured in quality-adjusted life-years (QALYs), and costs were measured in 2011 US dollars.

RESULTS

In the base case (US population, 49% male, 78% white, 13% African American, and 9% Hispanic, mean age, 46 years), screening followed by guideline-based treatment (using boceprevir as the direct-acting antiviral agent) of those with chronic HCV infection costs $47 276 per QALY. The overall HCV prevalence in the United States is reported to be 1.3%-1.9%, but prevalence varies markedly among patients with different numbers and types of risk factors. The marginal cost-effectiveness ratio (mCER) of screening decreases as prevalence increases. Below a prevalence of 0.84%, the mCER is greater than the generally accepted societal willingness-to-pay threshold of $50 000 per QALY and thus is not considered highly cost-effective.

CONCLUSIONS

Targeted screening is cost-effective when prevalence of HCV exceeds 0.84%. Prospective evaluation of a screening tool is warranted and should include comparisons with other screening strategies.

Costs of a public health model to increase receipt of hepatitis-related services for persons with mental illness

OBJECTIVE

This study examined the costs and impact on receipt of hepatitis and HIV testing and hepatitis immunization services of a public health intervention model that was designed for use by persons with serious mental illness and co-occurring substance use disorders.

METHODS

Between 2006 and 2008, a random sample of 202 nonelderly, predominantly African-American males with a psychotic or major depressive disorder and a co-occurring substance use disorder was recruited at four community mental health outpatient programs in a large metropolitan area. Participants were randomly assigned at each site to enhanced treatment as usual (N=97), including education about blood-borne diseases and referrals for testing and vaccinations, or to an experimental intervention (N=105) that provided on-site infectious disease education, screening of risk level, pretest counseling, testing for HIV and hepatitis B and C, vaccination for hepatitis A and B, and personalized risk-reduction counseling. The authors compared the two study groups to assess the average costs of improving hepatitis and HIV testing and hepatitis A and B vaccination in this population.

RESULTS

The average cost per participant was $423 for the intervention and $24 for the comparison condition (t=52.7, df=201, p<.001). The costs per additional person tested was $706 for hepatitis C, $776 for hepatitis B, and $3,630 for HIV, and the cost per additional person vaccinated for hepatitis was $561.

CONCLUSIONS

Delivery of hepatitis and HIV public health services to persons with serious mental illness in outpatient mental health settings can be as cost-effective as similar interventions for other at-risk populations.

Cost effectiveness of hepatitis C-related interventions targeting substance users and other high-risk groups: a systematic review

BACKGROUND AND OBJECTIVE

In developed countries, injection drug users have the highest prevalence and incidence of hepatitis C virus (HCV) infection. Clinicians and policy makers have several options for reducing morbidity and mortality related to HCV infection, including preventing new infections, screening high-risk populations, and optimizing uptake and delivery of antiviral therapy. Cost-effectiveness analyses provide an estimate of the value for money associated with adopting healthcare interventions. Our objective was to determine the cost effectiveness of hepatitis C interventions (prevention, screening, treatment) targeting substance users and other groups with a high proportion of substance users.

METHODS

We conducted a systematic search of MEDLINE, EMBASE, CINAHL, HealthSTAR and EconLit, and the grey literature. Studies were critically appraised using the Drummond and Jefferson, Neumann et al. and Philips et al. checklists. We developed and applied a quality appraisal instrument specific to cost-effectiveness analyses of HCV interventions. In addition, we summarized cost-effectiveness estimates using a single currency and year ($US, year 2009 values).

RESULTS

Twenty-one economic evaluations were included, which addressed prevention (three), screening (ten) and treatment (eight). The quality of the analyses varied greatly. A significant proportion did not incorporate important aspects of HCV natural history, disease costs and antiviral therapy. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (less costly and more effective) to $US603,352 per QALY. However, many ICERs were less than $US100,000 per QALY. Screening and treatment interventions involving pegylated interferon and ribavirin were generally cost effective at the $US100,000 per QALY threshold, with the exception of some subgroups, such as immune compromised patients with genotype 1 infections.

CONCLUSIONS

No clear consensus emerged from the studies demonstrating that prevention, screening or treatment provides better value for money as each approach can be economically attractive in certain subgroups. More high-quality economic evaluations of preventing, identifying and treating HCV infection in substance users are needed.

Resource use and cost of hepatitis C-related care

BACKGROUND

Chronic hepatitis because of the hepatitis C virus (CHC) is a major health problem that can lead to decompensated cirrhosis, hepatocellular carcinoma, and eventually death, all of which are associated with significant healthcare costs.

AIM

To update the cost of care of CHC according to the different severity stages of the disease in a west European country (Belgium).

METHODS

Medical records of 157 patients, who were referred to the medical specialist at different stages of disease, were reviewed to identify the medical costs over a follow-up period of 3 years or 2 years in the case of liver transplantation (LT). Six disease stages were defined on the basis of histology (Metavir classification) and/or clinical data.

RESULTS

In comparison with mild disease, the cost increased 1.6 times in the case of decompensated cirrhosis, 1.9 times in the case of hepatocellular carcinoma, and 3.4 in the case of LT. The costs for medication, hospitalization, and ambulatory care were, respectively, on the one hand, 81, 8, and 11% for mild disease and, on the other, 18, 79, and 3% for LT. In the case of a sustained viral response, the cost of follow-up within 3 years decreased by 45% for patients with mild and moderate disease.

CONCLUSION

Antiviral treatment is the most important factor governing cost in mild and moderate disease, but once complications of CHC occur, hospitalization costs far exceed the cost of antiviral therapy. Already during the first 3 years of follow-up, sustained viral response decreased the cost significantly. Treatment of patients with CHC in an early stage has the potential to be cost-effective.

Cost effectiveness of screening strategies for early identification of HIV and HCV infection in injection drug users

OBJECTIVE

To estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT).

DESIGN

Dynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15-59).

METHODS

We considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS

Adding HIV and HCV viral RNA testing to antibody testing averts 14.8-30.3 HIV and 3.7-7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior.

DISCUSSION

Although annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3-6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.

Structural frameworks and key model parameters in cost-effectiveness analyses for current and future treatments of chronic hepatitis C

OBJECTIVES

Published economic evaluations have reported available treatments for chronic hepatitis C to be cost-effective as part of the current approach to disease management, but as standards of care evolve, their approach to modeling should be reconsidered. This study aimed to review structural frameworks and key model parameters as reported in current economic evaluations for treatments for chronic hepatitis C, and model the impact of variability across parameters on results.

METHODS

A systematic review of studies published from 2000 to 2011 was performed. Studies were retrieved from five electronic databases using relevant search strategies. Model structures, disease progression rates, utilities, and costs were extracted from included studies, and were qualitatively reviewed and incorporated into a cost-utility model.

RESULTS

Thirty-four studies were appropriate for data extraction. A common pathway of six disease states was identified. In some studies the early disease stages and/or the decompensated cirrhosis state were further subdivided. Large variability in values used for disease progression rates, utilities, and costs were identified. When incorporated into a model, incremental cost-effectiveness ratios (ICERs) varied: in the least favorable scenario, peginterferon plus ribavirin was dominated by interferon plus ribavirin; and in the most favorable scenario, peginterferon plus ribavirin dominated interferon plus ribavirin ($8,544 per quality-adjusted life year [QALY]; costs are given in 2008 US dollar amounts). Using mean values the ICER was $15,198 per QALY.

CONCLUSIONS

Current models use a simplistic structure resulting from the lack of available data reflecting patient heterogeneity. Key model parameters are currently based on a small number of studies and the variability across these values can affect the interpretation of results.

Direct medical care costs among pegylated interferon plus ribavirin-treated and untreated chronic hepatitis C patients

BACKGROUND

Hepatitis C virus (HCV) is a common and expensive infectious disease. The current standard of care for HCV infection, pegylated interferon with ribavirin (PEG-RBV), is costly and has a significant adverse event profile.

AIM

To quantify the direct economic burden of HCV infection and PEG-RBV treatment for HCV.

METHODS

Using a large administrative claims database, we evaluated the medical and prescription drug costs of patients with HCV from 2002 to 2007. A cohort of patients with PEG-RBV was 1:1 propensity score-matched to a cohort of untreated HCV patients. Multivariate models adjusted for demographic and clinical characteristics in evaluating the effect of PEG-RBV treatment on direct medical expenditure.

RESULTS

The matched analysis included 20,002 patients. PEG-RBV-treated patients had higher total direct medical costs ($28,547 vs. $21,752; P < 0.001), outpatient pharmacy costs ($17,419 vs. $2,900; P < 0.001), and outpatient physician visit costs ($894 vs. $787; P < 0.001), but lower inpatient costs ($3,942 vs. $9,543; P < 0.001) and emergency room costs ($366 vs. $505; P < 0.001). After multivariate adjustment, PEG-RBV use was associated with an additional $9,423 in total direct medical costs and an additional $12,244 in HCV-related total medical costs.

CONCLUSION

Total HCV-related medical costs are higher for treated than untreated patients, driven mostly by higher outpatient pharmacy costs, which outweigh higher HCV-related inpatient costs incurred by untreated patients.

Reasons for compliance or noncompliance with advice to test for hepatitis C via an internet-mediated blood screening service: a qualitative study

Background

Hepatitis C virus (HCV) is mainly transmitted by exposure to infected blood, and can lead to liver cirrhosis and liver cancer. Since the onset of HCV and the development of liver cirrhosis usually are asymptomatic, many HCV-infected individuals are still undiagnosed. To identify individuals infected with HCV in the general population, a low threshold, internet-mediated blood testing service was set up. We performed a qualitative study examining reasons for compliance and noncompliance with advice to test for HCV via the online blood testing service.

Methods

Semistructured telephone interviews were conducted with 33 website visitors who had been advised to test for HCV (18 testers, 15 non-testers). Transcribed interviews were analyzed qualitatively and interpreted using psychosocial theories of health behavior.

Results

Reasons for testing pertaining to the online service were: the testing procedure is autonomous, personalized test advice is provided online, reminder emails are sent, and there is an online planning tool. Reasons for testing not specific to the online service were: knowing one's status can prevent liver disease and further transmission of HCV, HCV is curable, testing can provide reassurance, physical complaints are present, and there is liver disease in one's social environment. Service-related reasons for not testing pertained to inconvenient testing facilities, a lack of commitment due to the low threshold character of the service, computer/printing problems, and incorrectly interpreting an online planning tool. The reasons for not testing that are not specific to the online service were: the belief that personal risk is low, the absence of symptoms, low perceived urgency for testing and treatment, fear of the consequences of a positive test result, avoiding threatening information, and a discouraging social environment.

Conclusions

Features specific to the online service played a significant role in motivation to test for HCV above and beyond the more conventional perceived health benefits of HCV testing. However, some online specific features were considered problematic and need to be adapted. Methods and strategies for dealing with these impeding factors and for improving compliance with testing via the online service are outlined.

Using mass media and the Internet as tools to diagnose hepatitis C infections in the general population

BACKGROUND

Many individuals with hepatitis C virus (HCV) infection are undiagnosed.

PURPOSE

This study describes the development and the use and outcomes of a mass media campaign, combined with an Internet risk assessment and an Internet-mediated blood-testing procedure for HCV to identify individuals infected with HCV in the general population.

METHODS

From April 2007 to December 2008, individuals in HCV risk groups were referred to an online, previously validated risk-assessment questionnaire at www.heptest.nl. Individuals at risk could download a referral letter for a free, anonymous HCV blood test in a nonclinical setting. Test results could be obtained online, 1 week later, using a personal log-in code. Anti-HCV-positive participants were requested to visit the Public Health Service for confirmation and RNA testing. Chronically HCV-infected individuals were referred for treatment. Data were analyzed in 2009-2010.

RESULTS

The website attracted 40,902 visitors. Of the 9653 who completed the questionnaire, 2553 were at risk for HCV (26.4%). Main reported risk factors were a blood transfusion prior to 1992 and noninjecting drug use. Of the 1480 eligible for the blood test, 420 opted for testing (28%). HCV antibodies were detected in 3.6% (n=15, 95% CI=2.1%, 5.7%); of the 12 with a chronic HCV infection, six began treatment.

CONCLUSIONS

Internet-mediated risk-based testing for HCV has proved to be a feasible and effective strategy to identify undiagnosed HCV infection in the general population. All HCV-infected individuals belonged to hard-to-reach populations. Test uptake was 28%, which is high for an online project that includes blood testing. Because Internet-mediated testing is low-cost, this strategy holds promise for future screening.

Candidate hepatitis C vaccine trials and people who inject drugs: challenges and opportunities

People who inject drugs (PWID) are at high risk of HCV. Limited evidence of the effectiveness of prevention interventions and low uptake of treatment in this group highlight the need for increased investment in biomedical interventions, notably safe and efficacious vaccines. While several candidates are currently in development, field trials in PWID present challenges, including ethical issues associated with trial literacy, informed consent and standards of care. Significant biological and social factors and differences between HIV and HCV suggest that HCV warrants targeted vaccine preparedness research to lay the groundwork for successful implementation of future trials.

Establishment of a successful assessment and treatment service for Australian prison inmates with chronic hepatitis C

OBJECTIVE

To evaluate the assessment and treatment outcomes of a prison hepatitis service.

DESIGN AND SETTING

A retrospective, observational cohort study of prison inmates who attended hepatitis clinics from 1996 to 2005 at correctional centres in New South Wales.

PATIENTS

Inmates who attended the clinics, including a nested case-control series of patients who received antiviral treatment and age- and sex-matched patients who did not receive treatment.

MAIN OUTCOME MEASURES

Demographic and clinical characteristics of patients who attended the service; correlates of selection for antiviral treatment; and clinical and virological outcomes of treatment.

RESULTS

Of the 1043 inmates who attended the clinics, 851 were men (82%) and 994 (95%) were referred for HCV infection; the mean age for this group was 33 years (range, 18-74 years). In the case-control series (185 treated and 186 untreated patients), selection for treatment was not biased by culturally and linguistically diverse background, current methadone treatment or psychiatric status. In the treated group, 76 of 138 genotyped patients had a genotype that is predictive of favourable treatment response, and a small minority of those with available liver biopsy results had established cirrhosis (7/119 patients). Of treated patients for whom complete follow-up data were available, 55% achieved sustained virological response and 100% adhered to therapy. In addition, treatment episodes were not especially complicated.

CONCLUSION

Although the prison population has high rates of injecting drug use and poor mental health, imprisonment offers an opportunity for assessment and treatment of chronic HCV infection.

Undiagnosed hepatitis C on the general medicine and trauma services of two urban hospitals

The inpatient medical service may be an important location to identify undiagnosed hepatitis C virus (HCV) infection. We conducted a cross-sectional HCV prevalence study in consecutive patients aged 18-65 admitted in a three-month period to two urban hospitals' general internal medicine and trauma services. Patient sera were anonymously screened for anti-HCV antibody with an enzyme-linked immunoassay and, when anti-HCV positive (+), for HIV. Health system records were examined for prior HCV testing or diagnosis or an HIV diagnosis then linked anonymously to test results. Multivariate logistic regression was used to examine associations of patient and health care factors with unknown HCV+ status. Of 786 unique patients tested (60.3% of all admitted patients), 62 (7.9%) were HCV+ without a prior HCV+ test or diagnosis while 61 patients (7.8%) tested HCV+ but had prior HCV+ test or diagnosis. Of 62 patients with unknown HCV+, 6 (9.7%) were HIV+ but only 3 had a prior HIV diagnosis; of 61 patients with known HCV+, all 9 (14.8%) HIV+ had been diagnosed. Among the 640 patients with prior unknown HCV status, an HCV+ test was strongly associated with age: 50-65 (adjusted odds ratio [AOR] 5.44, CI 2.20-13.48) and age 36-49 (AOR 4.65, CI 1.91-11.32) versus. 18-35. In this anonymous study, we could not obtain HCV risk factor data but the positive and negative predictive values of HCV testing all inpatients with an unknown HCV status were 99.3% and 99.0%, respectively. In similar urban general medicine and trauma services, broader efforts to test for HCV in inpatients aged 36-65 may be warranted.

HCV-related burden of disease in Europe: a systematic assessment of incidence, prevalence, morbidity, and mortality

Background

Hepatitis C virus (HCV) is a leading cause of chronic liver disease, end-stage cirrhosis, and liver cancer, but little is known about the burden of disease caused by the virus. We summarised burden of disease data presently available for Europe, compared the data to current expert estimates, and identified areas in which better data are needed.

Methods

Literature and international health databases were systematically searched for HCV-specific burden of disease data, including incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and liver transplantation. Data were collected for the WHO European region with emphasis on 22 countries. If HCV-specific data were unavailable, these were calculated via HCV-attributable fractions.

Results

HCV-specific burden of disease data for Europe are scarce. Incidence data provided by national surveillance are not fully comparable and need to be standardised. HCV prevalence data are often inconclusive. According to available data, an estimated 7.3–8.8 million people (1.1–1.3%) are infected in our 22 focus countries. HCV-specific mortality, DALY, and transplantation data are unavailable. Estimations via HCV-attributable fractions indicate that HCV caused more than 86000 deaths and 1.2 million DALYs in the WHO European region in 2002. Most of the DALYs (95%) were accumulated by patients in preventable disease stages. About one-quarter of the liver transplants performed in 25 European countries in 2004 were attributable to HCV.

Conclusion

Our results indicate that hepatitis C is a major health problem and highlight the importance of timely antiviral treatment. However, data on the burden of disease of hepatitis C in Europe are scarce, outdated or inconclusive, which indicates that hepatitis C is still a neglected disease in many countries. What is needed are public awareness, co-ordinated action plans, and better data. European physicians should be aware that many infections are still undetected, provide timely testing and antiviral treatment, and avoid iatrogenic transmission.

[Prevention of hepatitis C virus infection in drug users]

The high prevalence and incidence rates of the hepatitis C virus (HCV) infections in drug users demonstrate the urgent necessity for a coordinated national prevention strategy. In the shadow of HIV/AIDS the necessary attention to the rapid spreading of the hepatitis C in drug users was started late, without being able to reach the public attention level of HIV/AIDS. The present efforts in the primary and secondary prevention of the hepatitis C in drug users are obviously not sufficient to reduce the prevalence with long-lasting results. Substitution treatment is of central relevance in the prevention of hepatitis C in opiate-dependent subjects, but requires, as current data of the HCV incidence of substituted opiate dependents illustrate, a stronger HCV-specific accentuation. Further settings, which are relevant for the group of intravenous drug users, have to be accessed and sensitized. Furthermore structural and political efforts are necessary, in order to develop a systematic and evidence-based answer to the challenge of the HCV spreading in drug users, in particular due to the fact that a German HCV strategy is still lacking.

The costs of breast cancer in a Mexican public health institution

Breast cancer (BC) is the second leading cause of death as a result of neoplasia in Mexico. This study aimed to identify the direct and indirect costs of treating female outpatients diagnosed with BC at a Mexican public hospital. A cross-sectional, observational, analytical study was conducted. A total of 506 medical records were analyzed and 102 were included in the cost analysis. The micro-costing process was used to estimate treatment costs. A 17-item questionnaire was used to obtain information on direct and indirect costs. Of the 102 women with BC included in the study, 92.2% (94) were at Stage II, and only 7.8% at Stage I. Total direct costs over six months for the 82 women who had modified radical mastectomy (MRM) surgury were US$733,821.15. Total direct costs for the 15 patients with conservative surgery (CS) were US$138,190.39. We found that the total economic burden in the study population was much higher for patients with MRM than for patients with CS.

Market uptake of new antiviral drugs for the treatment of hepatitis C

BACKGROUND/AIMS

Peginterferon plus ribavirin is the state-of-the-art antiviral therapy for prevention of serious complications of hepatitis C. Our aim was to compare market uptake of and access to these drugs across Europe.

METHODS

We collected launch and sales data for peginterferons for 21 countries in the WHO European region and compared country-specific sales rates. Additionally, we converted sales figures into patient numbers and related those to country-specific hepatitis C prevalence, taking into account genotype distribution, patient characteristics and practice patterns.

RESULTS

Peginterferon sales rates differed considerably across countries. The earliest, most rapid and highest adoption rates were in EU founder states, followed by EU members that joined after foundation, and EU non-member states. Most new member states showed a marked increase in sales. By the end of 2005, approximately 308,000 patients had been treated with peginterferons in the 21 countries evaluated. The number of patients ever treated ranged from 16% of prevalent cases in France to less than 1% of cases in Romania, Poland, Greece and Russia.

CONCLUSIONS

Peginterferon market uptake and access differed considerably across Europe, suggesting unequal access to optimised therapy. Besides budget restrictions, national surveillance and treatment policies should be considered as reasons for market access variation.

Critical role of hypoxia and A2A adenosine receptors in liver tissue-protecting physiological anti-inflammatory pathway

Whole body exposure of wild type control littermates and A2A adenosine receptor (A2AR) gene deleted mice to low oxygen containing inspired gas mixture allowed the investigation of the mechanism that controls inflammatory liver damage and protects the liver using a mouse model of T cell-mediated viral and autoimmune hepatitis. We tested the hypothesis that the inflammatory tissue damage-associated hypoxia and extracellular adenosine --> A2AR signaling plays an important role in the physiological anti-inflammatory mechanism that limits liver damage during fulminant hepatitis. After induction of T cell-mediated hepatitis, mice were kept in modular chambers either under normoxic (21% oxygen) or hypoxic (10% oxygen) conditions for 8 h. It was shown that the whole body exposure to hypoxic atmosphere caused tissue hypoxia in healthy animals as evidenced by a decrease in the arterial blood oxygen tension and increase of the plasma adenosine concentration (P < 0.05). This "hypoxic" treatment resulted in significantly reduced hepatocellular damage and attenuated levels of serum cytokines in mice with acute liver inflammation. The anti-inflammatory effects of hypoxia were not observed in the absence of A2AR in studies of A2AR gene-deficient mice or when A2AR have been pharmacologically antagonized with synthetic antagonist. The presented data demonstrate that total body hypoxia-triggered pathway provides protection in acute hepatitis and that hypoxia (upstream) and A2AR (downstream) function in the same immunosuppressive and liver tissue-protecting pathway.

Review article: a pharmacoeconomic analysis of thrombocytopenia in chronic liver disease

BACKGROUND

Patients with chronic liver disease commonly experience thrombocytopenia resulting from disease or treatment. Such patients often require multiple platelet transfusions, and consequently can experience associated complications including systemic infection, iron overload, and platelet refractoriness.

AIM

To discuss the limited data available on the impact of thrombocytopenia on the medical procedures and their associated costs.

RESULTS

Thrombocytopenia and its treatment can have a negative impact on outcomes and cost of therapy; costs associated with platelet transfusion can constitute a significant portion of the hospital budget. Inability to initiate or complete antiviral therapy for chronic hepatitis C infection due to low platelet counts can lead to dose reduction or discontinuation, lower efficacy, increased risks, and increased overall costs. Routine medical procedures can be complicated, prolonged, or precluded as a result of severe thrombocytopenia.

CONCLUSION

Novel therapies can safely and effectively prevent or treat thrombocytopenia in this patient population with chronic liver disease resulting in improved quality of care and significant cost savings in addition to improving treatment outcomes and quality of life (QOL) measures.

Review article: thrombocytopenia in chronic liver disease

BACKGROUND

Thrombocytopenia is a common finding in advanced liver disease. It is predominantly a result of portal hypertension and platelet sequestration in the enlarged spleen, but other mechanisms may contribute. The liver is the site of thrombopoietin (TPO) synthesis, a hormone that leads to proliferation and differentiation of megakaryocytes and platelet formation. Reduced TPO production further reduces measurable serum platelet counts.

AIM

This paper describes the scope of thrombocytopenia in chronic liver disease and assesses the clinical impact in this patient population.

METHODS

A medline review of the literature was performed pertaining to thrombocytopenia and advanced liver disease. This data is compiled into a review of the impact of low platelets in liver disease.

RESULTS

The incidence of thrombocytopenia, its impact on clinical decision making and the use of platelet transfusions are addressed. Emerging novel therapeutics for thrombocytopenia is also discussed.

CONCLUSIONS

Thrombocytopenia is a common and challenging clinical disorder in patients with chronic liver disease. New therapeutic options are needed to safely increase platelet counts prior to invasive medical procedures as well as to counteract therapies that further exacerbate low platelets, such as interferon. An ideal compound would be orally available and safe, with rapid onset of action.

Economics of chronic hepatitis B and hepatitis C

Although not all patients develop progressive liver disease, chronic hepatitis B and chronic hepatitis C infections cause substantial morbidity and mortality worldwide. To address this need, many new antiviral treatments have become available over the past 10 years. While safety, efficacy, and therapeutic indications have been well established for these agents, the economics of antiviral treatment have become increasingly a focus of discussion for physicians, policymakers, and health payers. In this paper, we will elucidate some economic principles using examples from the treatment of hepatitis B and C. In particular, we will examine the considerations in estimating drug costs, methods for performing economic analyses and lastly summarize published cost-effectiveness analyses for antiviral treatments of chronic hepatitis B and chronic hepatitis C. This review should help clinicians understand economic issues regarding new drugs and answer questions about whether the clinical benefit provided by a medication justifies its expense.

Barriers to care of chronic hepatitis patients in Latin America

Delay in diagnosis of chronic hepatitis due to HCV or HBV is mainly caused by lack of information about these prevalent and life-threatening disorders. Diagnostic tests are either not easily available or not requested by primary care physicians. When cases positive for hepatitis-B markers or anti-HCV are found, misleading guidance may be given to patients. Absence of symptoms associated with lack of information is another barrier to the care of chronic hepatitis patients. Management of these diseases is not simple, and treatment options and schedules are in rapid and continuous evolution. Surveillance of patients with chronic hepatitis before, during and after antiviral therapy is mandatory. For patients with no indication for therapy, identification of optimal follow-up frequency constitutes a problem, as does determination of the correct amount and type of diagnostic tests to be used. Another important barrier to care of patients with chronic hepatitis is the absence of an ideal drug, namely, one that is inexpensive, does not have collateral effects, and has very high percentages of cure or resolution. Access to therapy is uncertain, and the side effects of interferon frighten some patients and physicians. Lack of adherence to the medication, early interruption, and the need for other supportive therapies are frequent barriers to successful treatment.

Nationwide increase in hospitalizations and hepatitis C among inpatients with cirrhosis and sequelae of portal hypertension

BACKGROUND & AIMS

Advanced liver disease and complications of portal hypertension are common indications for hospitalization. Our objectives were to characterize longitudinal trends in incidence, characteristics, and outcomes of patients hospitalized with complications of portal hypertension using a nationally representative data set.

METHODS

Admissions for complications of portal hypertension (hepatic encephalopathy, ascites, or variceal bleed) were identified from the Nationwide Inpatient Sample between 1998 and 2003 using International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes. International Classification of Diseases, 9th Revision, Clinical Modification procedural codes were used to identify liver transplantation and portosystemic shunt procedures. National estimates for incidence of hospitalization over time, in-hospital mortality, and hospital charges accounted for survey design.

RESULTS

Hospitalization rates increased significantly by 5% annually between 1998 and 2003, particularly in the Northeast and the South. The prevalence of hepatitis C-related advanced liver disease among these hospitalized patients increased from 12.9% to 23.7%, and in those with HCV and concurrent alcohol-related disease the rate increased from 5.6% to 11.2%. US population-based in-hospital mortality increased modestly from 1.9 to 2.1 per 100,000 (P<.001), with hepatorenal syndrome as the strongest predictor of death (odds ratio, 9.5; 95% confidence interval, 8.4-10.7). The inflation-adjusted total economic burden of decompensated cirrhosis increased from $1.15 billion to $2.1 billion during the 6-year period (P<.003).

CONCLUSIONS

A significant increase in the incidence of hospitalization for complicated portal hypertension between 1998 and 2003 and a growing burden of hepatitis C-related disease have profound economic impact and underscore the need for interventions to prevent progression to advanced liver disease.

Controversies in and challenges to our understanding of hepatitis C

Discovered in 1989, the hepatitis C virus (HCV) continues to cause significant morbidity and mortality world-wide despite a huge research commitment to defining and understanding the virus and the disease it causes. This paper discusses a number of areas where progress in the management of the HCV have not kept pace with the scientific understanding of the HCV. It is suggested that in the fields of HCV prevention and providing access to treatment, practice falls short of what could be achieved. The role of alcohol in the pathogenesis of HCV liver injury is discussed. Discrimination against those with HCV infection and particularly those in prison settings fails to match good clinical practice. The complicated processes of sharing information between specialty groups is also discussed in an attempt to optimise knowledge dissemination in this field.

Functional and phenotypic characterization of peptide-vaccine-induced HCV-specific CD8+ T cells in healthy individuals and chronic hepatitis C patients

Only very limited information on phenotype and function of vaccine-induced CD8+ T cells is available for humans. We investigated hepatitis C virus-specific CD8+ T cells after vaccination with the HCV peptide-vaccine IC41 which includes 5 MHC-class I and 3 MHC class-II-restricted epitopes. In healthy subjects, IC41 induced both HCV-specific central memory as well as effector CD8+ T cells which rapidly expanded upon antigen exposure in vitro. IFNgamma production was dependent on formulation of the synthetic peptides with the adjuvant poly-l-arginine. In chronic HCV patients, the frequency of HCV-specific CD8+ T cells increased after vaccination with a decline of CD45RA-positive effector memory cells in some but not all patients. Thus, this study suggests that HCV-specific memory cells can be induced by peptide vaccination and that a reversion of functional impaired phenotypes by therapeutic vaccination is possible in chronic HCV infection.

Chronic hepatitis C

Antiviral therapy is approved by NICE but too few patients receive it

The economics of hepatitis C virus

Hepatitis C virus is a disease of major public health significance throughout the world in terms of overall morbidity and mortality and in its economic consequences and demands on medical resources. The global economic burden of this disease has yet to be fully realized. In this article the authors discuss the economic burden of hepatitis C, the economics of therapy, and the economics of its prevention and screening.