Basic Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 21, 2019; 25(11): 1327-1340
Published online Mar 21, 2019. doi: 10.3748/wjg.v25.i11.1327
Economic evaluation of the hepatitis C elimination strategy in Greece in the era of affordable direct-acting antivirals
Ilias Gountas, Vana Sypsa, George Papatheodoridis, Kyriakos Souliotis, Kostas Athanasakis, Homie Razavi, Angelos Hatzakis
Ilias Gountas, Vana Sypsa, Angelos Hatzakis, Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
Ilias Gountas, Angelos Hatzakis, Hellenic Scientific Society for the Study of AIDS and Sexually Transmitted Diseases, Athens 11527, Greece
George Papatheodoridis, Department of Gastroenterology, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens 11527, Greece
Kyriakos Souliotis, Faculty of Social and Political Sciences, University of Peloponnese, Korinthos 20100, Greece
Kostas Athanasakis, Department of Health Economics, National School of Public Health, Athens 11521, Greece
Homie Razavi, Center for Disease Analysis, Lafayette, CO 80026, United States
Author contributions: Gountas I and Hatzakis A conceived the study; Gountas I performed the modelling and drafted the manuscript; Hatzakis A coordinated the study; Sypsa V, Papatheodoridis G, Souliotis K, Athanasakis K and Razavi H provided essential inputs and contributed extensively to writing the manuscript; All authors contributed to model interpretation and approved the final version.
Conflict-of-interest statement: No conflicts of interest.
Data sharing statement: No additional data are available.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Angelos Hatzakis, PhD, Doctor, Senior Researcher, Senior Scientist, Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 22 Mikras Asias Str., Athens 11527, Greece.
Telephone: +30-210-7474058 Fax: +30-210-7474058
Received: October 16, 2018
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
Research background

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).

Research motivation

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.

Research objectives

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.

Research methods

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.

Research results

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.

Research conclusions

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.

Research perspectives

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.