Published online Mar 21, 2019. doi: 10.3748/wjg.v25.i11.1327
Peer-review started: October 16, 2018
First decision: December 5, 2018
Revised: February 20, 2019
Accepted: February 22, 2019
Article in press: February 22, 2019
Published online: March 21, 2019
Hepatitis C virus (HCV) infection is a major global public health problem. Greece has one of the highest rates of chronic HCV (CHC) infection in Europe, and approximately 33% of the chronically infected patients are at advanced fibrosis stages (≥ F3).
Greece faces a substantial economic crisis, which has resulted in more than 50% cut off in the public pharmaceutical expenditure. Therefore, it is important that every proposed healthcare intervention be accompanied by a cost-effectiveness analysis.
The main objectives of the study are (1) to estimate the required interventions to achieve elimination using updated information for direct-acting antiviral treatment coverage, (2) to compute the total costs (including the indirect/societal costs) of the strategy, and (3) to identify whether the elimination strategy is cost-effective/cost-saving in Greece.
To project the future burden of disease and to estimate subsequent future costs, we used a previously validated, Excel-based disease progression model constructed by the Center for Disease Analysis. This model simulates the progression of HCV-infected persons through the various stages of the disease, according to the METAVIR scoring system, with appropriate transition probabilities between stages.
Progression was simulated by multiplying the total number of cases at a particular stage of disease by the appropriate progression rate to the next stage. Newly infected patients can enter the model at any year, progress through the disease stages based on progression rates, and exit the model on: (1) spontaneous clearance of HCV; (2) achieving sustained virological response rates; and (3) death (all-cause or HCV-related). Thirty-six cohorts every 5 yr of age and gender were used through 84 yr of age. Individuals older than 85 were treated as one cohort. Each year, one-fifth of the population in each age group, except for 85 and older, was moved to the next age cohort to simulate aging after taking into consideration mortality. Treated patients with sustained virological response rates were considered cured, and they had the same risk of hepatocellular carcinoma and similar mortality as the general population.
The analysis showed that while overall HCV prevalence in Greece would decline, disease burden related to HCV and associated costs would continue to grow. To achieve the elimination targets, 90000 patients need to be treated between 2015-2030. It was estimated that the investment (direct costs) of the intervention would range from €2.1-2.3 billion by 2030, while about €1.1 billion would be lost due to premature deaths or decreased productivity (indirect costs). The overall cumulative cost of HCV elimination in Greece would range from €3.2 and 3.4 billion by 2030. The model showed that the cost per averted disability-adjusted life years by 2030 would be between €8330-€13380. Furthermore, the HCV elimination strategy is cost-saving, as €560-€895 million would be saved by 2035.
Our study highlighted that without the implementation of large awareness or screening programs, HCV elimination cannot be achieved, due to suboptimal treatment coverage. To eliminate the disease, significant public health reforms should be implemented (e.g., enhance harm reduction programs, implement case-finding, linkage to care interventions). Although the elimination of HCV is a costly investment, our analysis showed that it is also a cost-saving intervention, irrespective of the uncertainty of the future direct-acting antiviral cost in Greece, as the proposed strategy reduces the disease morbidity and mortality and restores productivity of the HCV-infected population.
Elimination of HCV is a demanding public health intervention, which poses significant challenges in the Greek health care system. Nevertheless, our analysis highlighted that HCV elimination is a cost-saving intervention.