Cost-effectiveness and budgetary impact of HCV testing, treatment and linkage to care in U.S. prisons.

BACKGROUND: Hepatitis C virus (HCV) testing and treatment uptake in prisons remains low. We aimed to estimate clinical outcomes, cost-effectiveness (CE), and budgetary impact (BI) of HCV testing and treatment in United States (U.S.) prisons or linkage to care at release.

METHODS: We used individual-based simulation modeling with healthcare and Department of Corrections (DOC) perspectives for CE and BI analyses, respectively. We simulated a U.S. prison cohort at entry using published data and Washington State DOC individual-level data. We considered permutations of testing (risk factor-based, routine at entry or at release, no testing), treatment (if liver fibrosis ≥F3, for all HCV-infected or no treatment) and linkage to care (at release or no linkage). Outcomes included quality adjusted life years (QALY); cases identified, treated and cured; cirrhosis cases avoided; incremental cost-effectiveness ratios (ICER); DOC costs (2016 US $); and BI (healthcare cost/prison entrant) to generalize to other states.

RESULTS: Compared to "no testing, no treatment and no linkage to care", "test all, treat all, and linkage to care at release" increased the lifetime sustained virologic response by 23%, reduced cirrhosis cases by 54% at a DOC annual additional cost of $1,440/ prison entrant, and would be cost-effective. At current drug prices, targeted testing and liver fibrosis-based treatment provided worse outcomes at higher cost or worse outcomes at higher cost/QALY gained. In sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs.

CONCLUSIONS: Although costly, widespread testing and treatment in prisons are considered of good value at current drug prices.